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Patient Story: Helping Mr. James Learn to Walk Again

Patient Name

Mr. James

Age/Gender

64-year-old Male

Social

Prior to a fall, Mr. James was able to care for himself independently (with the exception of driving). Following his return home from rehab, Mr. James remained completely bed-bound with the inability to ambulate and perform any ADLs or IADLs. Though ordered, skilled home health had not started care, nor had Mr. James received any form of physical rehab. Mr. James’ caregiver, who lives with him, is his mother who revealed he has a learning disability which can impede his ability to understand information and self-advocate.

Medical history

History of right hip fracture, Seizure disorder, Hyperlipidemia, and DMII


The Prospero Impact

The patient, referred to as Mr. James for anonymity, is a 66-year-old male with a history of right hip fracture, Seizure disorder, Hyperlipidemia, and DMII. The patient recently had a fall while walking to his mailbox with his walker resulting in a fracture to his right hip. He had hip surgery followed by a three-week acute rehab stay for physical therapy. Prior to Mr. James’ fall, he was able to care for himself independently (with the exception of driving). Since his return home from rehab, Mr. James had remained completely bed-bound with the inability to ambulate and perform any ADLs or IADLs. Though ordered, skilled home health had not started care, nor had Mr. James received any form of physical rehab. Mr. James’ caregiver, who lives with him, is his mother who revealed he has a learning disability which can impede his ability to understand information and self-advocate. 

Following successful patient identification and communication from naviHealth to Prospero upon patient Rehab discharge, the Prospero Care Team met Mr. James for his initial visit. At this time, the Nurse Practitioner discovered the physical, safety, and quality of life concerns impacting Mr. James. He had not been able to visit his PCP as planned due to his inability to walk or get out of bed safely. The Prospero provider connected with Mr. James’ PCP to order home health services to include skilled nursing, physical therapy, and an aide with the hope these services could increase his strength to the point he could safely make an in-person visit to his PCP for the post-hospital visit. However, the Prospero social worker made a wellness call to Mr. James and quickly recognized he was not improving in mobility, and also not receiving assistance with ADLs. Prospero performed an acute visit and then promptly helped Mr. James admit to the hospital appropriately for Failure to Thrive. The Prospero NP and SW worked alongside the hospital RN care manager to coordinate care for Mr. James and help him move to SNF service.

Mr. James is currently receiving inpatient physical therapy and the care he needs to progress towards his health goal. Prospero continues to coordinate with his family, actively involving them–monitoring his care and therapy as he strives to safely walk again. His sister, who is an RN, is also now involved and advocating for him to ensure he receives the required therapy for a safe discharge home. Mr. James has shared his gratitude for the impact of Prospero, which was made possible by the naviHealth team. We will continue to serve and support Mr. James and his family.