Last issue we described what ADRC Information and Assistance Specialist's do to partner with you to improve post-treatment success at home for the persons we serve.   Things like service listings, Options Counseling, Medicare, Medicaid and other benefits information, etc.   As promised, this issue we will illustrate through an example story how working together as partners can improve success at home after hospitalization. The story is true the names of course have been changed to protect privacy.

Charlene was hospitalized at age 75 for a dislocated shoulder and bruised ribs after a bad fall at home. After an overnight stay, her daughter picks her up. At discharge they receive instructions for the newly prescribed pain medication and are told to make a follow-up appointment with Charlene's primary care physician.   Because Charlene is over age 60 the discharge planner also gives them the phone number for the Aging & Disability Resource Center (ADRC) and encourages them to call about resources for help Charlene may need at home. Her daughter drops her off at home, along with her medications and enough groceries for a couple of days. Though Charlene's shoulder is expected to mend easily, the pain meds make her groggy and a little dizzy, and she still has the bad cold she was nursing before the fall. After a couple of days she calls her daughter who has been feeling overwhelmed herself. Her daughter suggests they call the ADRC. Charlene agrees because she has been feeling lousy since the fall and has had difficulty making meals or doing anything around the house.

An Information and Assistance (I&A) Specialist meets with Charlene and her daughter at her home to complete an assessment and find out what Charlene needs and wants for her recovery. Information uncovered by the assessment reveals that Charlene has chronic congestive heart failure, is on a number of medications, and taking supplements in addition to the new pain meds. They discuss her daughter's situation and her ability to assist, new pain medications and possible side effects and the importance of managing her congestive heart failure condition. In addition they talk about the things that Charlene is struggling with at home. Together with the help of the I&A Specialist they come up with a plan to improve Charlene's recovery and avoid future falls.  

• Charlene will give her pharmacist a list of the supplements she is taking to be reviewed with her current medications for possible negative interactions and/or side effects.  
• She will make a follow-up appointment for this week with her primary care physician to get treatment for her cold to avoid pneumonia and discuss the suggestions from the pharmacist.
• Charlene's daughter will take her laundry home to get it caught up and call her each of the next four days to check on her.
• Charlene will hire an in-home worker who will make main meals to put in the freezer to be micro waved and eaten in the next five days and clean the kitchen and bathroom.

Charlene feels that in a week if she can avoid lifting and get good rest and nutrition she will be much stronger.   The I & A Specialist will call in two weeks to see if they need any further assistance.

All of us are being challenged by the Federal Government to improve post-treatment success at home for the persons we serve.  We all know what a challenge this can be when persons minimize their needs and over estimate their informal supports.   Working together we can help persons and their caregivers who are experiencing medical problems and the challenges of aging recognize their needs and help them put together the right plan to improve post-treatment success at home.