Concierge: Ashley Valentin
Patient’s Age: 66-years-old
Admission Date: 12/11/21
Admitted from: Stony Brook University Hospital
Discharge date: 3/21/22
Discharged to: Home with private hire aides
Length of stay: 70 days
Reason for Stay: Falls with an Achilles tendon injury; right lower extremity pain swelling. There was a decrease in strength, transfers, reduced balance, and need for assistance.
How did the patient hear about St. James? A Previous positive experience.

Details of Experience:
Ms. Ben is a 66-Year-old woman who lives alone. Ms. Ben was hospitalized at Stony Brook University Hospital due to a fall, which resulted in an Achilles tendon injury. The team at the hospital spoke with Ms. Ben about a skilled nursing facility to be discharged for the next step. Ms. Ben knew exactly where she wanted to go since she had been at St. James and had a positive experience.

Ms. Ben was admitted to the St. James community on December 11, 2021. Within an hour of arrival, Ms. Ben was welcomed and evaluated with familiar friendly faces by the nurses and staff. Within twenty-four hours, she was evaluated by the interdisciplinary team, including case management, social work, integrative therapy, and therapeutic recreation, who worked to tailor and individualize care plans. Ms. Ben’s goals with physical therapy and occupational therapy were to increase balance, increase lower extremity strength, safely perform toileting tasks using adaptive equipment, perform bed mobility and safely negotiate two steps to enter her home. All these goals were able to be accomplished while maintaining special precautions for her Achilles tendon injury.

Ms. Ben knew the road to recovery was a long and strenuous one; however, she had experienced the St. James rehab team and knew she had support from the team. Since she had the same Physical and Occupational Therapist, she had the confidence and rapport that she needed to be able to meet her goals. She went from needing one-hundred percent complete assistance to the toilet to needing only twenty-five percent minimal assistance. Ms. Ben’s positive attitude was able to encourage other roommates. Her work with the rehabilitation team continued to progress, and she was soon able to walk a maximum distance of one-hundred and seventy-five feet with a contact guard. During this time, she was supported by her wonderful case manager, who was able to assist her in finding private hire aids at home for her discharge plan.

Ms. Ben and the team at St. James met her goals and went home with assistance from private hire aides. Reflecting on her time with St. James, she stated, “I wouldn’t be able to get back up each time without the amazing staff. The time they have spent with me and explaining the process of each step is just so incredible.”