Mom’s OK After A Stroke, Even At A Distance

Marjorie is a 75 year old woman who was brought to the hospital by her neighbors, having been found wandering in her yard confused. She is widowed and living alone, with a son in New York city and daughter in Colorado. LifeSpan was called by her son, who had taken a leave from his job to visit her in the hospital.

She was seen in the hospital by a LifeSpan nurse, who reviewed the chart and talked with her doctors. A plan was made for transfer to a subacute facility for rehabilitation after the initial hospitalization. In this instance, the stroke caused mild physical deficits as well as more severe memory and judgment impairments. The plan was set for Marjorie's return to home with home health care support, but a secondary plan for Assisted Living placement if she did not progress enough for her safety awareness and ability to care for herself to return to normal.

Her progress in the Subacute facility (Subacute care is for those who do not have the strength for a full rehabilitation regimen, 3 to 5 hours of rehab per day). Subacute care is given in nursing facilities that have a strong rehab team. The advantage of placement in such a facility (rather than a garden variety nursing home) is that the skill level of the clinical staff (doctors, nurses and therapists) is generally much better, and if the resident has a setback, they can more easily be placed within the facility rather than being transferred to another one later. Those facilities that take Medicare and Medicaid can be more flexible than those who accept only Medicare. Most of the skilled nursing facilities that take Medicare and Medicaid also have Independent Living and Assisted Living portions as well. If the resident and family elect such a facility, a lifelong contract can be made to care for the resident even if they outlive their assets. The hard part is finding a facility that meets the resident’s and family’s needs, and is a quality facility that will enable a high quality of life for the resident.

Marjorie transferred from the Subacute portion of the facility to the Assisted Living Portion with some adjustments. The Care Manager suggested a service to work with the resident to  select the clothes, personal belongings and furniture that would best fit the Assisted Living apartment. They packed and moved the belongings to the new apartment without the son or daughter having to worry about the details. The Care Manager also suggested choices for the family of an elder lawyer to preserve the assets of the resident while complying with the laws judging such transference of wealth within the family. The Care Manager also helped find a real estate specialist who prepared the house for sale , and sold it. The Care Manager also attended doctor appointments with the resident both in  the facility and follow-up appointments with specialists.

The Care Manager worked on behalf of Majorie and her family to assure that she was progressing physically (i.e., eating well, sleeping well, not losing weight, addressing physical complaints such as pain, adjustment to the new environment).  The Care Manager reviewed the pharmacy bills and adjudicated over-charge issues.

Eventually, it became clear that Marjorie was slowly losing her memory and orientation. An inter-facility transfer to a portion of the facility that has special expertise with those who have cognitive impairments (i.e., Alzheimer ’s disease) was negotiated. Here again, the Care Manager was able to negotiate the service level and rate of payment on behalf of the patient and family. The family was kept informed of all expenses, transactions, and likely upcoming issues; they were provided with documents that detailed progress of their mother’s condition, expenses and to her necessary details.  

Marjorie’s children were greatly relieved that they did not have to travel frequently  to take care of details regarding the house, facility transfer, and other unforeseen details. They felt assured that their mother was getting the best possible care and that the cost of care, while higher than they imagined, was negotiated for them on their behalf by a Care Manager who was familiar with all the facilities in the region andwith  what costs were reasonable or not.