Maintaining quality of life at home after hospitalisation
Summary
Susan is very elderly and has dementia, and was recently hospitalised following a fall and fractured hip. HomeWise Health helped her through hospitalisation, advocating for rehabilitation to avoid loss of mobility and helping Susan return home.
Situation
Susan is in her 90’s and loves to go for a coffee at the harbourside beach near her home. However, on a trip to the beach, Susan tripped and broke her hip. The ambulance confirmed Susan had a fracture and transferred her to the nearest hospital where she underwent a hip replacement.
The HomeWise Clinical Care Manager (CCM) a Registered Nurse, liaised with Susan’s financial Trustee and a separate Health Guardian to organise 24 hour carer support in the hospital to reduce Susan’s agitation in the unfamiliar environment. HWH carers were on hand to assist Susan with regular fluids and maintain her dietary intake, monitoring her pain levels. Along with regular visits by the CCM and communications with the stakeholders to keep them updated, Susan’s recovery went smoothly.
Challenges
The hospital wanted to discharge Susan directly home after six days post op, with limited mobility and sutures in place. HomeWise’s CCM advocated for Susan to be transferred to a rehabilitation facility to maximise her recovery to regain her quality of life, because she was otherwise precluded from this pathway because of her advanced age and diagnosis of dementia. She arranged for HomeWise Health carers to attend Susan day and night in the rehabilitation facility to ensure this arrangement suited all the interested parties.
Once Susan moved to the rehab facility, HomeWise’s CCM needed to monitor the rehabilitation till Susan was safe to go home and carers continued to give one to one care in the new environment and minimised the disruption to Susan’s routines.
HomeWise’s CCM noticed inappropriate wound dressings and medication side effects that could have stalled or worsened Susan’s recovery.
Outcomes
The CCM handled all aspects of the transition from hospital to rehab, making sure that Susan received continuity of care. Our CCM contributed to the rehab process with feedback to the facility about correct wound dressings and symptom control, and the carers ensured Susan had continuity and consistent care. She also ensured the necessary equipment and home modifications were in place in time for Susan’s return home.
5 weeks after the fall, Susan was discharged to her home and has since resumed regular daily outings. Weekly physiotherapy was organised at home to maintain her function. A nutritionist was engaged to recommend diet changes and prescribe supplements to correct deficiencies following the surgery and blood loss, in collaboration with Susan’s GP. After two months, Susan is back to excellent health and enjoying life able to walk around her neighbourhood and is back to playing the piano.
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