Shining a light on what is possible with patient advocacy.
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. Throughout 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.
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 daily.
After completing an assessment, Angel On My shoulder identified key issues that were affecting 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.
A family member discovered a $23,000 check was cashed by their aunt’s caregiver. On the recommendation of their Eldercare attorney, Angel On My Shoulder was called in for assistance.
After a complete assessment of the 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.
Mr. F was in the emergency room 4 times in the past month for abdominal pain. GI studies were all 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 in 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.
Angel On My Shoulder saw an opportunity to leave long term care. By advocating to have Mrs. B’s feeding tube removed, she could leave long term care and return home to her husband.
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 that without our support, she would have remained in long term care.
Today, she enjoys her home with a trained caregiver supporting her needs and her loving family.
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 (AOMS) to provide personalized patient care coordination and advocacy. We understand time is of the essence. Within 24 hours, AOMS made an onsite visit to the facility and coordinated and consulted with attending physicians, facility staff, and family.
After reviewing medications and consulting with the doctor, 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 showing improved cognition. Within a week, he was ready for 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.
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 before 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 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 vertebroplasty surgery. She 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 advocate for her as well. Quickly we identified an opportunity for her to return home – she was still within her 60 day Medicare day limit of rehab.
We coordinated with her primary care physician (PCP) and neurosurgeon, suggesting readmission to skilled rehab. After a lengthy rehabilitation, and pain specialist support, Mrs. G has returned to her home with 24/hr caregivers.
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 evaluation included social history, which helped in long term planning and relationship building.
It was determined that Mrs. H would stay in California with her niece. Immediately we went to work to find a new primary care physician (PCP), 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, supervised, and educated caregivers. She became a friend to Mrs. H and 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.