Holistic care at its best

Summary

Robert suffered a stroke and a broken leg. His recovery had been very slow due to an inattentive nursing team at his rehabilitation hospital and poor coordination with his physician. Working with Robert’s son, HomeWise’s Clinical Care Manager (CCM) a Registered Nurse, coordinated his treatment plan and accelerated his rehabilitation, helping Robert regain lost weight and live independently again.

Situation

After Robert suffered a stroke he was in a rehab facility for treatment. While he was in rehab, however, Robert fell and broke his leg in an accident, further complicating the treatment plan.

HomeWise Health received a call from Robert’s son, who lives in Brisbane. He was concerned about the quality and coordination of care his father was receiving in Sydney at rehab. The facility was generally well-regarded and familiar to HomeWise Health. Robert’s condition however required attention from multiple doctors from different disciplines, and important elements of care were being lost in the communication.

Challenges

When our CCM, an experienced Nurse, first visited Robert, he had been in rehab for nearly two months. His leg was fitted in a boot, but no member of the care team at the rehab facility had any knowledge of a plan to remove the boot. Robert’s orthopaedist had visited the facility twice over two months, and a physical therapist had been by several times. Despite this, a communication gap between the parties involved in Robert’s care began to grow, as no one had responsibility for taking charge of Robert’s recovery.

In addition to the challenge of removing the boot and coordinating physical therapy, Robert had also lost nearly a third of his body weight while in rehab. Aside from borrowing several cans of protein supplement from another patient, the rehab facility also had no plan in place for weight gain.

Outcomes

HomeWise’s CCM immediately developed a weight gain plan, adding calories and nutrients into Robert’s diet. Soon, he began to gain weight. HomeWise also involved the family in the plan, explaining what Robert needed and how they could help. She encouraged the family to bring Robert’s favourite foods when they visited.

The CCM also spoke with the orthopaedist and physical therapist to clarify the plan for removing the boot. She then informed the rehab staff and included them in that plan. Within several weeks, the orthopaedist removed the boot, and the physical therapists began focusing on building muscle and coordination so Robert could walk again.

Seven weeks after HomeWise’s initial consultation, Robert was ready for discharge from rehab and now lives independently at home.