Patients Age: 77
Admission Date: 2/2/2018
Admitted From: St. Luke’s Cornwall Hospital
Discharge Date: 5/8/2018
Discharged To: Home
Length of Stay: 95 Days
Reason for stay: To lower fall risk and strengthen core muscles to go home.

Details of Experience:

Adele Flanagan came to us through St. Luke’s Cornwall Hospital, where she was recovering from a fall at home and a difficult onset of CHF. Sandy Gomas, our RN Care Manager and Patrick Gallagher, our RN Supervisor, greeted Adele and her family upon arrival. Katie Cullum, Patient Concierge, and Tom Cirrincione, Director of Rehabilitation, and Vincent Zaccheo, our Dietician, met with Ms. Flanagan a short time later.

Adele had one goal: to return home. The team realized Adele would be a challenging case, but Adele was more than willing to put to work in to make it happen. With some logistic challenges at home, the team and the Flanagan family knew it would be best to have Adele able to ambulate with a walker rather than solely relying on the wheelchair. Goal setting would be most important, with finding Adele small, intermediate goals, would lead to the large goal of walking. This would take an interdisciplinary approach through rehabilitation, nursing, activities and dietary.

Kiran, occupational therapist and Yosef, physical therapist, saw the desire and drive in Adele to actively participate in rehabilitation. Both put together a series of short term goals, such as using positioning bars with limited assistance for bed mobility, safely use the toilet with limited assistance using grab bars and ascend/descend 3 stairs using handrails with assistance. Within 3 weeks, Adele met these goals and was ready for additional challenges.

With the success of meeting her short-term goals, Adele was ready to focus on her long-term goals. These goals included adding a raised toilet seat and lessening verbal prompting. This allowed Adele to increase her toileting functionality from assistance of one to only stand by assistance. In addition, physical therapy now began to focus on Adele’s standing and balance. The longer she could safely stand, the more independence she would rediscover. After increasing her standing and balance, Adele was able to completely dress herself and perform all hygiene tasks. 12 short weeks ago, she was unable to perform any of those tasks independently.

Adele ended her journey with us on May 8, 2018. In order to make sure her safe journey continued at home, Adele received knee braces and at-home strengthening exercises from our Rehabilitation team. In addition, Sandy, our RN Care Manager, performed a pre-discharge home visit to make sure the home environment was set up for Adele’s return. Adele was thrilled to be going home, saying, “Who knew I could do all this? You believed in me. I guess the belief and support from all of you was exactly what I needed!”