Ms. B was diagnosed with Parkinson's disease, and had no family, and limited resources. She thought she had to manage her health by herself, but her doctor knew contacting Angel On My Shoulder could to help change her present life circumstances. She consented to our support.
After our initial assessment, it was determined that Ms. B did not have the resources for the medications prescribed. As a result, she felt she had few choices to manage her health, and her limited support system made life appear even more overwhelming to her. To make things even more complex, she was one of many people today caught in the circumstance of making too much money for assistance, but not enough to manage her health.
We gained Ms. B's trust by empowering her with choices to improve the difficulties she faced. Together, we established a treatment plan with short and long term goals. These included obtaining health insurance, and setting up a support network.
Our nurses accompanied her to support groups and medical appointments until she was comfortable going alone. We navigated the community transit system together, and helped make new social connections.
Ms. B learned she could be successful with her treatment plan. She soon began to feel better once she had her medications and the social support.
Ms. B has decided it is time for her to give back to the community that supported her, and she is currently working as a volunteer.
Ms. J's 91 year old very independent aunt (Mrs. H) was visiting from Oregon. Mrs. H required unexpected orthopedic surgery during her stay in California. Ms. J was concerned, as she knew her aunt had a complex health issue, but no details. She was told of the services of Angel On My Shoulder and called for assistance. Our case manager was assigned to the case the next day.
We contacted healthcare providers in Oregon to complete a comprehensive assessment, which assisted in answering the health questions needed for surgery. Part of the assessment included social history, which assisted in long term planning and relationship building. When it was determined Mrs. H would stay in California with her niece, we went to work to find a Primary care physician, caregivers and support for home modifications for Ms. J.
Mrs. H had never addressed long term planning including advanced directives. Angel On My Shoulder's Case Manager educated both Mrs. H and Ms. J on choices and directives. Our Case Manager continued to visit Mrs. H, at which time she coordinated homecare and supervised and educated caregivers. She became a friend to Mrs. H, an advocate for her. Ms. J was able to work during this stressful time and received the peace of mind that she had provided the best care possible for her aunt.
When the patient picked up the Angel On My Shoulder brochure in her doctor's office, she was looking for a nurse to help her return to her home. Mrs. G was placed in assisted living after a vertebreplasty and was mistakenly taking her thyroid medications for her pain medications.
Mrs. G did not have family to advocate for her, but was relieved to learn that not only could we help her return to her home, but we could advocate for her. We coordinated with her PCP and neurosurgeon, and suggested readmission to skilled rehab (she was within her 60 day Medicare days). After a lengthy rehabilitation, and pain specialist support, Mrs. G has returned to her home with 24/hr caregivers.
Mr. F was in the emergency room 4 times in the past month for abdominal pain. GI studies were all negative. His wife was exhausted with caregiving, and all of the children lived out of town.
Mr. F was 82 years old and worked part time in Los Angeles. A month prior to the onset of abdominal pain, he was diagnosed with angina, CHF and atrial fib. Dr. R called Angel On My Shoulder for caregiver support and coordination care at discharge. An assessment was done in the patient's home, to determine the needs of the client.
We met with Mr. F often during the first month and placed caregivers to meet his physical and social needs. The assessments identified the time frame of when the abdominal pain started. In reviewing records with Primary care MD, it was determined the anticoagulation medication started was causing pain. The medicating was changed. Mr. F's abdominal pain stopped, and his wife continued to enjoy the support of caregivers in the home. Mr. F returned to work part-time, with the support of his caregiver/driver.
When the wife of Mr. B came into the Neurologist's office she was overwhelmed and crying with frustration. Her once affable husband was now confined to a nursing home, confused and refusing to eat. She wanted him home!
Dr. M called Angel On My Shoulder to provide personalized patient care coordination and advocacy. An onsite visit to the facility along with coordination and consultation with attending physicians, facility staff and family was done in 24 hours.
After reviewing medications and consulting with Dr. M, a repeat CT scan determined that a revision of his VP shunt was needed along with a change in medications. Mr. B began to respond positively: he was sleeping well, eating once again, gaining strength and showed improved cognition. Within a week he was ready for a discharge home with caregivers.
Mr. B is now home enjoying his garden, and swimming at the community center with his family. We visit twice a month to monitor and help to coordinate his at home care under the direction of his providers.
Mrs. B had a stroke in January, and was continuing to have complications in the skilled nursing facility in April 2013. She had come close to utilizing all of her Medicare rehabilitation days. The family contacted Angel On My Shoulder to assist managing their Mother's care.
After requesting a second opinion of her medical status, it was determined she had developed a seizure disorder. At this time, she was receiving artificial nutrition from a feeding tube due to her inability to swallow safely. We knew if the feeding tube continued she would need to go to a long term care facility for the remainder of her life. (State of California regulations do not allow feeding tubes in most assisted living facilities, board and care or at home if unable to manage by yourself.)
Conversations with Client and family occurred to make them aware of their options for care. As her medical conditions stabilized, and her swallow improved, Mrs. B began to eat soft foods.
We saw an opportunity to offer a new plan to Barbara to leave long term care and return home to her husband by advocating for her to have her feeding tube removed.
The family, medical team and Angel On My Shoulder worked together over the next three months to support Barbara in meeting her goal.
Barbara has told us she knows without our assistance she would have remained in long term care. Today, she enjoys her home with a trained caregiver supporting her needs and her loving family.
A family member discovered a $23,000 check was cashed by the caregiver caring for their aunt. On the recommendation of their Eldercare attorney, they called Angel On My Shoulder for assistance. After a complete assessment of home situation, new caregivers were trained and placed in the home. Ongoing supervision of caregiver and financial oversight assured family this would not be repeated.
Our client was experiencing difficulty having her needs met at an assisted living due to mild cognitive impairment. She was no longer able to manage the coordination of care of her medical providers, and clearly communicate her needs. Her family lived out of state and were unable to assist her on a daily basis.
After completing an assessment, Angel On My shoulder was able to identified key issues which were effecting her quality of life. Through weekly visits with our client, and direct communication with medical providers, she is involved in activities at the assisted living and attending the appropriate medical appointments.
The family enjoys peace of mind, knowing their Mother is receiving the care she needs.
The children of our client felt it was time for their Mother to have in home assistance, but she disagreed. We suggested a compromise by providing weekly visits to assure our client’s safety, and observe that medications were taken.
On one of these visits, we found that our client had fallen and injured her shoulder, making it difficult to care for herself. Over the course of our visits, a relationship of trust was established, and our client agreed to a caregiver in the home. Today, she remains safe in her home and loves the support and companionship of her caregivers.