John is 84 years old with flu like symptoms. He was taken to the emergency room and was admitted for severe dehydration. After being in the hospital for two days, John was diagnosed with pneumonia along with several patients on the same floor. Due to this diagnosis, John was put on isolation protocol and could not leave his room for two weeks.
Once off isolation, it is determined that John needs a pacemaker for a pre-existing heart issue. His wife and four children are not sure why the pace maker was inserted and are hesitant to ask because they don’t want to be labelled a “difficult” family.
Four weeks have passed, and the family really would like to get John back home to his wife. No one has mentioned when he will be going home, and they are not sure who to ask. The nurses change every day and there are so many doctors that come and go they are not sure which one to ask. They have heard the word “dementia” mentioned a few times and they are not sure if they should be concerned. Does this mean dad won’t be going home? If he does go home will Mom be able to look after him?
The family gets increasingly worried, frustrated and overwhelmed so they decide to call Integrity Healthcare Consultants to see if they can help.
An IHC Consultant:
- Went to the hospital and had a family meeting with the multidisciplinary hospital team to discuss potential discharge
- Facilitated a safe and seamless discharge home setting up home care needs
- Educated family on when to take John to his GP or hospital
- Made suggestions of what the family should tell the GP about the hospital stay that John had in case information was not sent to the GP
- Did a medication review
- Created a personal health portfolio of his recent admission to hospital, current medications and recent diagnoses for John to keep with him in case he needed to return to the hospital
- Followed up after discharge to ensure that transition home was going well
The family was so grateful and had peace of mind knowing that dad was back at home safe and comfortable.