Returning to the community after a lengthy nursing home stay is wonderful, but it requires lots of action from the facility’s team!
A special resident admitted to Integrity Healthcare of Alton in 2015 with multiple medical diagnoses. Once the resident expressed an interest to return to the community, the Interdisciplinary Team met to discuss gearing his care toward rehabbing to home. The Nursing department first requested an order from his physician for discharge. The Therapy department assessed his needs for transferring himself in and out of bed and his occupational skills for completing his own activities of daily living and placed him on programs to increase these skills along with Restorative programs that the CNA’s could help with during care. In addition to arranging for a primary care physician in the community, Social Services contacted local apartments and completed applications until he was accepted. They also contacted outside agencies to assist him once he was on his own. IMPACT took the lead and set up home health, paid for his first month’s rent and the deposit, arranged for furniture and bought him groceries on his first day in the new apartment. The Business Office Manager made certain his income reached him. The front office arranged for transportation with the facility van. Housekeeping and Laundry packed up the resident’s belongings, and Activities had the other residents say a farewell during an activity.
Each discharge has its own hurdles to jump depending on the situation of the resident and/or family involved and the severity of needs for the resident. Each case is looked at for individual needs based on an assessment of the whole person; functionality, family, home health needs, transportation, different community physicians involved, adaptive equipment needed, income and so much more.
Our resident made his home with us for some time, and even though he passed away recently, he was able to live the rest of his life in his own home. We are Integrity! This is what we do … Care You Can Trust!
Submitted by: Cassie Lindow, LNHA
Integrity Healthcare of Alton