We just want Dad home from the hospital safely

We just want Dad home from the hospital safely
0 December 4, 2015


eorge” who is 83 years old is admitted to the hospital Christmas day with dehydration, weakness and confusion after spending the 3 previous days with flu like symptoms. 3 days after being admitted to the medical surgical unit “George” starts to cough, spike a fever and the oxygen levels in his blood have dropped requiring him to be administered oxygen; “George” is diagnosed with pneumonia and is moved to a private room and put under isolation limiting his ability to socialize with others and leave the room that he is in. A family member has remained with him as much as possible trying to get an understanding from the doctors and nurses what the next steps are and when will Dad be able to come back home? With nursing shifts changing and different doctors coming in and out of the room at different times of the day, no one seems to have an answer for the family. Four weeks goes by and “George” is feeling better, the pneumonia has cleared and George is moved to a semiprivate room on the infectious disease unit.


George is not able to go home because a pace maker has been inserted as recommended by the cardiologist. The family is unclear why it was needed but felt they shouldn’t question it in case the staff at the hospital got mad.


February comes and Dad has been in the hospital now for 6 weeks. The family has been coming and going everyday and their stress level is maxed out. They have heard the nurses on several occasions say something about “dementia” but haven’t explained what this means. “George’s” kids want to be present at the hospital to have the opportunity to discuss discharge plans with the doctor(s) which has proven to be extremely difficult not knowing when the doctors will be in to do their rounds. Nancy and her siblings are getting pressure at work for taking time off to be at the hospital and not meeting work deadlines. “Georges” daughter talks to a friend and explains what her father has been through and how confused and frustrated the family is. The friend suggests to the daughter that she call an RN that she knows in independent practice specializing in helping families with healthcare navigation, education and advocacy. “Nancy” the daughter calls Jana at Integrity Healthcare Consultants to inquire as to what can be done to assist the family.


Jana and Nancy discussed the current state of “George” and what the families goals and objectives are. “George” had been residing with his wife in a retirement facility and the family wants him to return home with his wife and receive home care as needed.


Jana went to the hospital where “George” was admitted and met him and his wife and kids. “George’s” son and daughter were power of attorney making it possible to have a meeting in the absence of “George”. A family meeting took place to discuss how Jana could expedite the discharge process and what that would entail. Jana spoke to the social worker and CCAC discharge planner assigned to “George’s” discharge to ensure both were communicating with each other. With Jana’s expertise in hospital discharges she was able to facilitate a seamless transition from hospital to home, with adequate homecare services arranged.


Three days after discharge Jana and Melissa a certified Geriatric nurse visited “George” and his wife at home to assess how he was coping after a successful transition. “George” presented in good spirits however, was unsteady on his feet and not oriented to his surroundings. After doing a medication review it was noted that two of the medications being taken by George could cause him to be unstable on his feet and likely the combination of both was the underlying factor of his unsteadiness. After being assessed by Melissa (who specializes in Altzheimer’s disease and dementia) it was apparent that “George” was suffering from 4th stage dementia and was in need of seeing a Geriatrician (A doctor who specializes in geriatrics). Melissa was able to discuss and educate the family on dementia and answer all of their questions.


“George” was booked to see his family physician the day after our home visit. Jana and Melissamade a list of questions that the family could address with “George’s” physician regarding his medication and post hospital discharge follow up.


“George” is currently living with his wife in their retirement facility. He is steady on his feet and is being monitored for his dementia. Homecare comes in three times a week to help with housework. “George’s” wife and family cannot believe the improvement that “George” has made, they confided that at one point they thought “George” ……was going to die.


At Integrity Healthcare Consultants (IHC) we are a team of specialized nurses dedicated to helping clients and their familiesnavigate our complex healthcare system effectively. As nurses we are familiar with the way the system works and the pitfalls to avoid.


The importance of educating families on what they are faced with cannot be overestimated. Knowing the options for treatment and feeling empowered to make informed choices is paramount to ones health journey.

    At IHC:

  • We will keep moving you and the health plan forward when you don’t have the energy.
  • We will put everything into perspective when you are frustrated.
  • We will answer your questions patiently when you are confused.
  • We will speak on your behalf when you feel too angry to talk.
  • We will step in and take the lead when you are feeling stressed.


For a complimentary phone consultation call IHC @ (416) 723-2190 or go to www.integrityhealthcare.ca

Posted in Article by jana