Client Profile:

Mrs. Anthony is a 78-year-old wife who has dementia and suffered a stroke. When she became a SeniorBridge client in June 2006, she was fighting bronchial pneumonia and a viral infection. She was on 11 different types of medications and required tube feeding 3 times daily. She needed some help with bathing, eating, dressing, walking and toileting. She lives with her husband Charles, 72, and has a daughter Joan, but they are not involved in her daily care. She has home health aides 24 hours a day, 7 days a week.

Situation:

Vacationing in Florida with her husband last winter, Mrs. Anthony, a well-known graphic artist, had a stroke and was hospitalized for 3 months until her family could safely move her to a rehab facility near her home. Mrs. Anthony also had moderate dementia, bronchial pneumonia, and a viral infection. She required tube feeding 3 times daily because of trouble swallowing after the stroke and needed some help with all other major activities of daily living. Charles and Joan, busy attorneys, are part of a large family living in the area who are concerned but unable to regularly participate in direct caregiving. Another attorney referred them to SeniorBridge when they realized that Mrs. Anthony needed services beyond what Medicare would allow, including someone to prepare her food. They were anxious and uncertain how to obtain personalized special care for her multiple problems while in rehab and upon returning home.

Solution:

Before transferring Mrs. Anthony to the rehab facility, the hospital referred the SeniorBridge care manager to a Medicare agency that could provide tube feeding. The care manager coordinated that service from the agency, Mrs. Anthony’s nursing care, and her medication management through the feeding tube. He also arranged for two personal care aides alternating daily 12-hour shifts to provide social support and assistance in her bathing, dressing, and toileting. He met regularly with the staff at the facility to monitor her condition and advocate for needed services. Mrs. Anthony returned home after her pneumonia cleared up and the viral infection was under control. Although she still gets easily fatigued, she is able to use a walker and goes through her life with the help of round-the-clock aides who enjoy working with her. Her husband and daughter are extremely relieved that she has found exactly the help she needed and see steady improvement in her very challenging condition. The rest of her family is amazed how bravely and innovatively she and SeniorBridge meet her many challenges.

Prognosis:

Creative solutions shortened the road to recovery.