Client Profile:

Until recently, the Bartons were living in chaos. Last year, Mrs. Barton, 100, was placed in a nursing home, and her devoted husband, 98, tried to take her home to care for her against medical advice. Both landed in the hospital. Mr. Barton has moderate dementia and mild heart disease, and Mrs. Barton has advanced dementia and is medically stable but frail and confined to a bed or wheelchair. She needs assistance in transferring from wheelchair to bed. They have no other family except elderly cousins who live too far away to help.

Situation:

The Bartons did not belong in the hospital, but Medicare would not pay for home health services because they did not need skilled nursing care. Clearly, they could not go home alone, although Mr. Barton and his lawyer who had power of attorney believed that somehow the couple could manage on their own. Fairly soon, however, demented episodes convinced the lawyer that special help was needed.

Solution:

The hospital’s discharge social worker contacted SeniorBridge to help work out a solution. A geriatric social worker put 24-hour services in place in their home, with two home health aides and a third caregiver who transferred Mrs. Barton in and out of bed. A SeniorBridge nurse now coordinates the care team, communicates with family physicians, and administers medication. At first, Mr. Barton would yell at the caregivers and drive them away. He would rail against their cooking because he felt like he could cook for his wife, even though he couldn’t remember that 2 days had gone by since they last ate. Now, he loves their cooking and is grateful for the caregivers.

Prognosis:

The Bartons can remain safely at home for the rest of their lives.