Patient Story: Supporting Transition to Hospice

Patient Name



65-year-old Male


Lives at home with wife (primary caregiver) and 4-year-old grandson

Medical history

Lymphedema, Defibrillator, HTN, CHF, COPD with oxygen dependency, Neuropathy, Prostate CA metastatic cancer, COPD, Orthopnea, Chronic respiratory failure, AFib, Dilated cardiomyopathy, Venous insufficiency, CKD4, MRSA, Spinal stenosis, Pulmonary HTN, GERD, OSA, MI, Atherosclerosis, Peripheral vascular disease


Wife reported patient was “in and out” of the hospital for the last year. Our records show at least 9 admissions over the last year. Almost always followed by SNF/Rehab placement.

The Prospero Impact

Louis did not have a PCP at the time he enrolled with Prospero. His wife was overwhelmed by caregiving for both him and their 4-year-old grandson, whom she has custody of.

Prospero helped Louis immediately by prescribing medications in the absence of a PCP and provided same day care for an abscess.

His Initial Plan of Care established the need for Serious Illness Conversation (hospice) and caregiver support.

Louis’s wife quickly placed her trust in the Prospero care team, calling the NP after-hours line on multiple occasions. The NP prevented his readmission to the hospital by providing in-home care and education. Louis’s wife thought he needed ER evaluation due to poor oral intake but Louis’s NP was able to treat him and prevent the admission.

“No one has ever explained his condition to me so clearly before.”

Louis’ wife

The Prospero care team helped Louis transition to hospice successfully. Prospero performed ongoing check-ins with Louis’s wife to ensure they were comfortable and supported during the transition and assisted the hospice RN and staff with a warm handoff in-home.

Louis is now comfortably nearing end of life, and he and his wife are supported.

Note: The patient’s name has been changed to protect his privacy.