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Patient Story: Meeting Patient Needs with Long-Term Care

Age/Gender

76-year-old female

Social

The patient is divorced and has been receiving support from her siblings. She requires dialysis three times a week and, at the time of referral, had skilled home health for wound care, physical therapy, and an aide to assist with ADLs. The patient had her initial visit from the Prospero NP in May, where she agreed to services.

Medical history

The patient had a history of ESRD, failure to thrive, DMII, TIA, CKD, tobacco use, anxiety disorders, noncompliance, and dependence on renal dialysis. She had also had three hospital admissions within two months with follow-up rehab stays, resulting in a referral to Prospero from her naviHealth SICC.


The Prospero Impact

The patient is a 76-year-old female with a history of ESRD, failure to thrive, DMII, TIA, CKD, tobacco use, anxiety disorders, noncompliance, and dependence on renal dialysis. She had also had three hospital admissions within two months with follow-up rehab stays, resulting in a referral to Prospero from her naviHealth SICC.

The patient is divorced and has been receiving support from her siblings. She requires dialysis three times a week and, at the time of referral, had skilled home health for wound care, physical therapy, and an aide to assist with ADLs. The patient had her initial visit from the Prospero NP in May, where she agreed to services. 

In that initial visit, our NP stratified her as High Complex after clinical assessment and set a visit cadence for frequent visits. During the Prospero NP’s second visit two weeks later, the caregiver (the patient’s sister) revealed she was overwhelmed trying to take care of the patient and her disabled brother. She was working on finding a safe place for the patient to reside as she wasn’t equipped to continue caring for the patient—the patient does not eat or take medications, and she regularly screams for help throughout the day. 

The caregiver requested hospital admission to help place the patient in a long-term-care facility. Once readmitted, LCSW provided ongoing care coordination with hospital SW, updating her on changes in care goals and noted caregiver burnout. Prospero NP/SW outreached weekly during the patient’s inpatient stay and followed up with the caregiver (sister). LCSW spoke with the sister and researched local housing options and resources to support the patient and, in turn, her sister. 

The patient is now safely residing in a long-term care facility permanently where she can receive the support she needs: round-the-clock—3x/week dialysis, physical therapy, medication monitoring, administration, and proper nutrition. Her sister has the peace of mind she needs to rest and recover from the stress felt from caring for the patient beyond her capacity.