Patients Age: 48
Admission Date: 11/6/13
Admitted From: Somers Manner Nursing Home
Discharge Date: 3/31/16
Discharged To: Home
Length of Stay: Approximately 3 years
Reason for Stay: Ongoing Rehabilitation, skilled nursing needs and long term placement
How did this patient hear about Grove Center?
Details of Experience:
Resident arrived to The Grove aprox 3 years ago as a transfer from a different facility. She was there due to having a diagnosis of COPD and arrived to us severely reconditioned. Our therapists immediately put her on our rehab program to build up her strength and prepare her to go home.
Unfortunately, due to the overall length of her hospital and rehab centers stays, this residents public housing provided apartment was taken away from her. At the time, her family was unable to provide a safe home discharge for her, so once she was brought up to her prior level of function, this resident transitioned from being a short term resident to a long term resident.
Along with COPD, over the next few years, she had multiple hospital stays and various diagnoses’s requiring the Grove to provide her with the necessary skilled care, along with an ongoing Rehab program.
The resident, being young and having many interests and hobbies, would get very involved in recreational programs, as well as even volunteering her time and creativity to assist in creating new programs and running current activities. Needless to say, she had a thirst for more than life at The Grove.
Abe,Concierge/Assistant Admin made it his mission to get this resident to some supportive, safe discharge, so she can make a life for herself out of The Grove. Her quality of life would be greatly improved by a discharge back to the community and the entire interdisciplinary team agreed that it would be the most positive plan of action for her future.
After lengthy discussions with members of her family, Abe was successful in coordinating with one of the resident’s sisters and setting a tentative discharge date!
With our eye on the prize, Team Grove sprung into action. The nursing departments focused on Medical education and training the resident to be able to self medicate and take care of certain medical treatments she is still currently prescribed. Her PT and OT ramped up her therapy sessions, focusing on range of mobility, ambulation, balance coordination, and re-integrating her association with all activities of daily life in a safe manner. The social worker and discharge planner coordinated all aspects of her homecare, visiting nurse services, as well as assisting in helping the resident get set up with social services outside of The Grove.
The concierge worked as a liaison between the resident and all other departments, ensuring all messages and requests were met. All in all, this was a huge success for Team Grove- but even more so for this resident. She was very thankful to all members of the team on her way out and is ready to tackle life in the community, once again.