“Judith”: The Flow of Integrated Care

February 21, 2014

lovely womanAn important aspect of delivering excellent patient-centered care is being very proactive in the care we provide. What patient-centered care means to our clinicians, hospice and support staff is doing whatever it takes to make the patients and their families as comfortable as possible. Our transition team uses the phrase “tucked in” to indicate that a patient is where they need to be and is receiving good care.  The following case study illustrates our approach to providing a style of care that we believe ultimately leads to every Housecall Providers patient being “tucked in.”

Clinician Teri Hiller, FNP, had a patient named “Judith” who was in her 90s and living in a locked, memory care unit in the West Hills. Her son “Patrick” was a caring and concerned son, and though living four hours away, was very involved in her care. He was enthusiastic when his mother became a Housecall Providers patient because, like many people suffering from Alzheimer’s, traveling to a medical appointment often seemed to exacerbate her condition.

When Teri started seeing Judith, she was very agitated, displaying a lot of confusion, anxiety, and depression as well as various other behavioral issues.  After Teri assessed Judith, she adjusted and changed some of her medications and worked collaboratively with the facility staff to address her mental health and physical issues so she would no longer have to leave the facility for treatment.

Once Judith became a Housecall Providers patient, her son was contacted by Polly Green, LMSW, to identify the health care goals for his mother. At the time, Polly was coordinating our Patient Centered Primary Care Home (PCPCH) project.  Polly spoke with Patrick on the phone. “I remember that the goals for his mother were simple and sweet,” Polly said.  “He felt very compelled to have her ears cleaned regularly and to coordinate this with her hearing aid specialist. Since he lived out of town, the telephone was their main source of communication.” Because he identified that as a goal, Teri arranged her visits to correspond with the hearing aid specialist and together they were able to keep Judith’s hearing at its best.

As Teri’s visits increased and the changes to her medication took full effect, Judith’s demeanor began to shift. “One day when I was there to check up on her, she says to me, ‘Watch what I can do’ and proceeds to take her walker and goes into a full-on sprint down the hallway. I couldn’t believe it! She was so fast; I couldn’t grab her in time. She was so proud that she had energy and was feeling so good. Every time I saw her, she always had a smile on her face and had something wonderful to say.  She was delightful,” Teri remembered.

Months passed. Then Judith had an accident, breaking her hip and her shoulder. She was admitted to the hospital and had surgery the next day to help manage her pain. Her recovery was not going very well and her health was declining. The family gathered at the hospital to discuss next steps. 

Polly, as a member of our transitions of care team, met with Patrick and his family because it is now protocol for the transition team to visit all patients who are hospitalized. “The family was so happy to see me,” Polly said.  “Because Patrick and I had exchanged various emails and calls relating to his mother’s health goals, a relationship had already been established between us. That made it quite a bit easier to walk into that hospital room.”

Patrick, his wife and Polly sat together in the alcove of the hospital and talked about what they had experienced thus far in the hospital and what the plan would be moving forward.  Polly did not know where the family was with making final care decisions, but wanted to suggest Housecall Providers Hospice as well as the other available hospice options in the area. “No, we want Housecall Providers Hospice,” they told her.  Polly gave the couple a hospice flyer and her card.  “They had nothing but praise for Teri and the care she provided his mother,” Polly said. “Over the weekend the hospital discharge planner called our hospice and made an appointment for the following Monday so that when she was discharged, it would be to our hospice.”

Judith was placed on Housecall Providers Hospice, but after just three days she passed. Three hospice nurses and a social worker were present at her death and that meant a lot to Patrick and his family who were not able to be there because they lived so far way. “Patrick could not have been happier with his mother’s care – knowing that someone was at her bedside made a big difference to the family. Prior to her death, she was more relaxed, engaging with people in the facility, she was smiling – enjoying life,” Teri said.

Housecall Providers’ hope for its patients and their families is that when crisis does strike, plans are in place that honor the wishes of the patient, and in turn, aid to alleviate undue stress to the caregivers and family members.” Polly added: “What makes this story so wonderful is the continuity of care – the flow of service from primary to hospice. More important though is that Judith was ‘tucked in’.”

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