Luciana is an 84-year-old woman living independently in La Crescenta who was recently admitted to St. Joseph Hospital suffering from chemotherapy induced neutropenia. Unfortunately for her, this was just the latest in a series of medical conditions afflicting her senior years. The list is lengthy, making every day a complex series of treatments addressing a UTI, ongoing sleep apnea, rheumatoid arthritis, ovary and breast cancer, hypertension, hyperlipidemia, hydronephrosis, hemorrhoids, severe hearing loss, ear disorder, diabetes type 2, degenerative arthritis of spine, chronic constipation, cataracts, back pain, and alopecia. Any one of these conditions alone would be a trial under the best of circumstances.
Luciana is blessed with three adult children – two boys and a daughter – though both sons live out of state. This means care responsibilities fall often to the daughter, augmented by some caregiver support. During Partners’ Care Transitions Choices home assessment visit following Luciana’s discharge from the hospital, her daughter reported feeling burnt-out and overwhelmed from the duties in caring for her mom. Delia, Partners’ Coach performing the home visit, identified the two most important issues facing the family were to prevent Luciana from being unnecessarily readmitted to the hospital and to assist her daughter in dealing with the demands of Luciana’s care. Delia also noted that mom was a strong candidate for long-term case management through Multipurpose Senior Services Program.
Fortunately, Luciana already had IHSS benefits, and as part of Delia’s assessment, she recognized that Luciana could benefit from additional support hours. Delia worked with Luciana’s daughter to contact an IHSS social worker to request a re-evaluation of Luciana’s circumstances with the goal of increasing her mom’s IHSS hours. After the request was made, an IHSS social worker performed a home visit and recommended that Luciana’s hours be increased. Not only will this get Luciana additional regular help but will help diminish the circumstances causing her daughter to feel burnt-out and overwhelmed.
Luciana’s daughter also told Delia that prior to her mother being hospitalized, her hearing had been “normal.” That changed during the hospital stay when she lost the ability to hear. Luciana and her primary care provider are still trying to determine what happened to affect her hearing. In the meantime, she communicates by “writing everything down on a piece of paper or using simple sign language”. This further supported Delia’s assessment that Luciana would benefit from long-term case management, and a referral to Partners’ MSSP program, and is scheduled for an evaluation at the end of October 2019. Lastly, since both Luciana’s daughter and caregiver provide medical transportation, Delia worked with the daughter to complete a Department of Motor Vehicles handicap placard application, which was approved by Luciana’s doctor. Since Luciana can walk, but challenged by distance, the handicap placard will allow them specialty parking to easily access appointments and outings.
These actions by Partners’ coach have helped see Luciana pass the critical point following her hospital discharge when she might have needed readmission. It has also resulted in a lessening of pressure on Luciana’s daughter, which also helps her provide her mom with better care. And, both mother and daughter deeply appreciate the help, support, and advice provided by Delia. A testimony to the success of Partners’ Care Transitions Choices program.