Excellence in Action: Where there’s a will, there’s a way- From hospice care to assisted living!
Our Paola, KS team recently had a success story with a patient who also happened to be the mother of one of the facility nurses. The patient had been battling bladder cancer and was then diagnosed with COVID-19. As a result of COVID-19, she experienced acute respiratory failure and required over six liters of supplemental oxygen. She also developed pneumonia and malnutrition with decreased intake. She had a very extensive medical history including COPD, anxiety/depression, bradycardia, and glaucoma making her situation even more complex.
Shortly after the patient was admitted to our facility, our therapy team performed risk-focused screens, noting that the patient could hardly sit and talk without severe shortness of breath. The focus of her care at that time was solely on providing comfort measures. Slowly, but surely, the patient began to feel better, and approximately 3 weeks after being admitted to the facility, she decided to stop hospice services and was evaluated by our therapy team. The patient’s goal was to regain enough independence to discharge to an assisted living apartment.
Upon evaluation, the patient presented with poor activity tolerance, poor balance, limited standing activity, minimal to moderate swallow dysfunction, and was consuming only 25% of her meals. Overall, she required assistance for all self-care tasks and as a result, most activities were completed at a seated level. The patient could complete gait with minimal assistance with a rolling walker for 20 feet. She was completing cognitive tasks with 70% accuracy.
The patient worked very hard in the 2 months that she was on our therapy caseload. Our therapy team, Ashita, PTA, Mark, PT, Lisa, COTA, Jennifer, OT, Andrea, COTA, and Danielle, SLP, utilized TMC Clinical Programs, including Balancing Act, Bodies in Motion (Functional Mobility), Dysphagia, and Mission Cognition to address the patient’s needs in a person-centered manner. Since the patient had COVID-19, she was in isolation for most of her stay, resulting in feelings of isolation due to the therapists’ limited ability to implement community mobility and group activities.
By the time the patient discharged from therapy, she had reached a level of minimum-slight dysfunction and required no verbal cues for swallowing. She was consistently consuming 75-100% at meals. She was ambulating with a 4-wheeled walker for 350+ feet with modified independence. Her balance had also improved. Every day she was completing her Activities of Daily Living (ADLs) with modified independence while weaning from supplemental oxygen completely! Along with her improved physical health, her ability to complete cognitive tasks improved, qualifying her to discharge to Assisted Living (AL).
Due to financial complications, the patient could not immediately discharge to AL, so our therapists created Functional Maintenance Plan (FMP) recommendations. This included patient, family, and caregiver education to assist patient with maintaining level of function.
The patient continued to work hard on her own, and as a result, continued to improve in her independence. No longer needing a device for mobility, PT assisted her in addressing higher-level balance and mobility goals.
After a brief return to the hospital for a medical concern, all therapy disciplines evaluated her upon her return to the facility. They worked collaboratively as a true interprofessional team and by the end of the month she was ambulating at the same level from her previous discharge. She began working with PT on gait without a device, walking up to 100 feet with Contact Guard Assist.
On her last day of therapy, our therapy team presented the patient with a plant as a housewarming gift for her new AL Apartment. Before she left, she rang the therapy graduation bell proudly and reported that she was going to hang up her therapy graduation diploma in her apartment and display her housewarming plant to always remember her therapists. In tears, she hugged everyone, telling them how much she loved them and will always remember her time with them.
In Paola, KS we know that where there’s a will, there’s a way, and we are ALL IN for helping our patients achieve their goals!