Success Story: Preventing Readmission into a Nursing Home for a Senior

Last Updated February 15, 2023

After fracturing his hip and shoulder from a serious fall at home, 85-year-old David recovered in a nursing facility where he received round the clock supervision and care. Complicating his recovery, David lives with numerous health conditions, including hypertension, high cholesterol, heart problems, arthritis, and depression. He also relies on an electric wheelchair for mobility due to weakness, joint pain, and stiffness in his lower extremities.

The Partners Multipurpose Senior Services (MSSP) program is designed specifically to help people like David stay in their home. It does this by assessing an individual’s circumstances, and where possible, creating a plan of social care that supports an individual’s desire to stay in their community of choice, close to family and friends.

During the transition back to his home from the nursing facility, David shared with his Partners MSSP Care Manager his desire to reduce his risk of falling and avoid returning to a nursing home. He also wanted an easier and safer way to move in and out of his house without major assistance, which was impossible with the rickety portable ramp he had.

Due to difficulties moving in and out of his house, David would often miss medical appointments, was unable to attend church with his family, or enjoy other family outings. His Partners’ Care Manager identified David at risk of feeling socially isolated and lonely, which could be a factor in his depression.

Through Partners’ MSSP, David was provided with an upgraded modular ramp with handrails. The new ramp allows him to safely exit and enter his home and the installed handrails help him avoid potential accidents that could lead to another injury and being admitted to the emergency room. MSSP also provided David with a portable emergency response device in the case of a fall’s incident, a new mattress designed to alleviate joint pain for his arthritis, as well as curb-to-curb transportation services to and from medical appointments and community events to reduce social isolation.

With the newly installed ramp and transportation services provided by MSSP, David can now attend church and participate in family events, which has significantly improved his mood. David also feels safer at home now with his newly installed handrails and emergency device and is grateful to the services provided to help keep him from being readmitted into a nursing home.

If you know a senior like David that could benefit for services and supports from Partners’ MSSP, please make a referral HERE

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