Services: Case Studies

Helping a Client Transition from Long-Term Care Back Home

The Challenge:
To assist a 95-year-old woman, who was receiving long-term care at a Massachusetts nursing and rehabilitation center, to return to her own home.

The Caregivers:
Over 20 total, including family members, healthcare, legal and financial professionals. Their important contributions needed to be coordinated and documented.

The Solution:
Customized, professional healthcare consulting that includes coaching, meeting facilitation, team communication, attendance at medical appointments and more.

The Result: 
With time, planning and consistent management, Mrs. R has been happily living in her own home since July of 2006.

The Challenge of Living Alone

In September 2005, Mrs. R, age 95, was hospitalized to treat shingles/herpes zoster. Until this point, Mrs. R had lived alone in her home. Since her closest family were two nephews who both lived out of state, a local Visiting Nurse agency supplied a home health aide several times a week to assist with her personal care.

Following surgery for spinal stenosis in 1998, Mrs. R became dependent upon a wheelchair and a Foley catheter. In 2005 she lived on the first floor of her home, which had been modified to include a wheelchair ramp and a first floor dining room converted to a bedroom. Although Mrs. R spent most of her day in the wheelchair, she was able to walk short distances using a walker. Despite the fact that Mrs. R had her groceries delivered and cooked for herself, upon admission to the hospital her nutritional status was depleted and may have contributed to her illness.

Transfer to Long-Term Care

After her hospital stay Mrs. R was transferred to a nursing and rehabilitation center for a course of short-term rehabilitation that included physical and occupational therapy, all covered by Medicare. Afterwards, Mrs. R became a full-time, long-term resident of this facility, although her wish was to return home.

The center provided Mrs. R’s meals, and the staff assisted with her personal care. However, she now required more services on a daily basis than she had in the past, and no one was able to oversee and coordinate her return home. As a result, her friends and family assumed she would stay at the long-term care facility for the duration of her life.

The Right Help to Return Home

Soon after her admission to the long-term care facility, Mrs. R retained the services of an Elder Law Attorney to assist her with legal and financial matters. During her first meeting with the attorney, Mrs. R. defined her goals:

• To return home to live
• To walk more often

To fulfill her wishes, the attorney knew that Mrs. R. needed coordinated care from a team of providers and someone to oversee these services consistently. He introduced Mrs. R. to personal healthcare consultant Dianne Savastano, Principal of Healthassist. 

The Solution: Healthassist Professional Healthcare Consulting

Dianne Savastano was able to step in and manage all of Mrs. R’s health care needs through a combination of personal heath care consulting, attendance at medical appointments, medical team communication management and other professional services.

Dianne first set up a meeting with Mrs. R’s long-term care facility team: the physician, the nursing director, the director of rehabilitation and the social worker. They determined that Mrs. R had no acute medical issues that would prevent her from returning home.  Although the team supported Mrs. R’s goal, they expressed reservations about her ability to thrive at home based on her experience prior to hospitalization. However, they were eager to assist with the transition – as long as it was effectively managed.

Healthassist Connects Mrs. R to Crucial Medical Services

Meanwhile, Dianne Savastano made an appointment for a consult with a local primary care physician whose practice specialized in the care of elderly individuals. The physician, who was certified in Geriatric Medicine, partnered with Mrs. R and Healthassist to care for her in her community.

To ensure a successful transition home, Healthassist recommended that Mrs. R hire a private 24x7 live-in caregiver. With Dianne’s assistance, Mrs. R interviewed two potential caregivers, and after discussion, selected her choice. To help Mrs. R meet her goals of improved walking and other functional abilities, Healthassist connected Mrs. R with a private physical therapist. The therapist’s role was to supplement any PT services Mrs. R might receive at home from the Visiting Nurse agency.

Healthassist Services Overview

Healthassist’s Dianne Savastano provided these customized services:

For the Transition Home from Long-Term Care

• Identified the right primary care physician for Mrs. R. in the community and established a close working relationship with this physician
• Facilitated the hiring of a 24x7 live-in caregiver
• Provided clear, concise communication to all Mrs. R’s caregivers, including the local Visiting Nurse agency
• Arranged for nursing visits to pre-fill Mrs. R’s medications
• Conducted a home assessment and coordinated the services to make Mrs. R’s home safe and convenient for the transition
• Connected Mrs. R to a private physical therapist to help her maintain and improve her walking skills

Ongoing Services

• Coordinates all medical care and attends all physician appointments with Mrs. R
• Facilitates communication among 20 medical personnel, caregivers, family members, friends and neighbors, and legal and financial services professionals
• Helps Mrs. R manage acute medical issues and temporary hospitalizations

With Healthassist overseeing her care, facilitating communication with her medical team, and advocating for her, Mrs. R lives happily in her home, surrounded by her books and cherished personal items, enjoying a view of the ocean from her own back yard.