“Sylvia”, 86, was referred to Partners by her health plan case manager following her admittance to Providence Tarzana Hospital. She had been suffering from severe diarrhea, bronchitis and a kidney infection.
A Partners home health coach, Delia Lezama, visited Sylvia at home to conduct an evaluation and needs assessment. Sylvia was surprised and grateful to have someone contact her following her discharge from the hospital – something she had not experienced before.
Sylvia has significant needs. In addition to the bronchitis and kidney infection, she also has COPD, anemia, osteoarthritis, a heart condition, vitamin D deficiency, hyperlipidemia, paroxysmal atrial fibrillation and a dilated aortic root. These multiple chronic conditions make it extremely difficult for Sylvia to undertake even the most basic daily activities, with meal preparation a particular problem. Living alone in a second floor apartment, Sylvia is unable to shop regularly, and even when she can reach the grocery store, carrying bags of food up two flights of stairs is impossible. Much to Sylvia’s delight, Delia was able to provide immediate assistance – helping Sylvia obtain a meals-on-wheels service that now delivers food seven days a week.
Sylvia was also struggling with her oxygen supply. She had called the company that delivers the oxygen tanks on several occasions, but had been passed from person to person without the issue being resolved, causing Sylvia a lot of stress and frustration.
Delia called the company and was able to get through to a supervisor, who apologized for the poor service and dispatched a new tank immediately. Delia also observed Sylvia’s low morale, and recommended she receive counselling services to help give her some emotional support. Having someone acknowledge the difficulties she’s experiencing and the toll this has taken on her happiness was a huge relief for Sylvia, and she readily agreed. Finally, Delia and Sylvia talked about the future, and what will happen if Sylvia is no longer be able to make decisions for herself. Again, Sylvia expressed her relief that she had someone to talk to, and was grateful that Delia was able to help her in the process of obtaining an advance directive.
“Like many of the people I see, Sylvia’s situation is very difficult,” said Delia. “Being able to provide a continuity of care following her release from the hospital has made an enormous difference to her emotional and physical well-being. That’s rewarding for her, for me, and for her health plan case manager.”
* Not client’s real name
