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Patient Story: Bringing Happiness Back

Patient Name

Walter

Age/Gender

64-year-old Male

Social

Prior to hospitalization, Walter lived in a boarding home with eight additional residents. There were 10 steps to enter the home and 17 steps to access his bedroom. Walter had no known next of kin or emergency contacts. He also faced financial insecurity, and was not able to read or write.

Medical history

OSA, CHF/CAD/HTN, DM, morbid obesity, CKD3, and anemia


The Prospero Impact

The patient, Walter, is a 64-year-old male with a medical history of OSA, CHF/CAD/HTN, DM, morbid obesity, CKD3, and anemia. After a recent hospitalization in August 2021 for treatment of hyperglycemia and syncope, he was referred to a skilled nursing facility (SNF) for additional care. During his stay, a Skilled Inpatient Care Coordinator (SICC) was assigned to coordinate his care. Through early engagement with the facility staff and the designated NP, she discovered Walter lived in a boarding home with a shared kitchen and bathroom for eight additional residents. The home had 10 steps to enter and an additional 17 steps to access his bedroom. Walter did not have any caregivers or emergency contacts nor had he ever been married or had children. In addition to a lack of a support system and financial resources, the SICC identified literacy concerns as Walter could not read or write, nor desired to learn. Walter was well known to the NP and she shared her concerns with the SICC regarding the patient’s difficulty managing his diabetes. The SICC worked with the facility care team to address Walter’s need for early stair training to return home. In addition, she requested both OT and ST work on developing tactics to assist Walter with self-management of his medications. Although he was improving functionally and the SICC was confident he could manage physically at home, she was concerned about his living situation and his compliance with managing his medications without support. As part of his discharge plan, she referred Walter to Prospero’s services.

During Prospero’s first interactions, the SICC’s concerns were confirmed and it was clear Walter was not taking his medications properly, nor did he have regular access to nutritious meals. Prospero also discovered that although Walter was able to access his bedroom, he spent most of his time in his van due to the discomforts within his home, including his worn mattress. Mutual goals included accessing resources to address his social determinants of health, assistance with medication management to control his diabetes, and pain reduction due to peripheral neuropathy and edema.

The Prospero care team worked, and is working, to address the physical, social, and emotional needs of the patient—often tapping into creative and effective methods of intervention. Social work has been involved with Walter for months to ensure ongoing access to needed resources in innovative, safe ways. In fact, due to Walter’s inability to read but great need for food stability, the social worker drove to the local Urban Ministries and had Walter follow her in his van so he could receive free groceries monthly and one free nutritious meal daily, which he is doing. Nursing has addressed the patient’s need to understand his medications and their administration by using a system of codes, charts, and shelf placement to overcome the literacy barrier. Walter is also receiving home PT and OT to reduce his pain and increase his activity. The team is also supporting his emotional health by regularly asking how he is feeling and by encouraging positive pursuits, such as working on what he loves, which is melding metal together to create art, butterflies in particular. 

Due to the collaboration between the NP, the SICC, and Prospero, Walter is now experiencing an enhanced quality of life. His heart failure is compensated, and he is eating regular, nutritious meals using identified community resources. He has also moved into a more comfortable space with a new mattress to aid in higher quality sleep. His diabetes is controlled, and he has not required hospitalization since returning home. He continues with Prospero and is keeping a daily log of what “brings him happiness”.


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