An Award Winning Case Study
Mrs. Mary Smith, a resident at Crosby Commons Independent and Assisted Living community was sent to a local hospital emergency room on a Saturday evening for evaluation of a medical emergency. Knowing that miscommunications can occur during this transitional process from the community to the ambulance and finally to the emergency room, Crosby Commons sent along a packet of information with the resident to assist the hospital staff in their initial assessment. Included in the packet was:
- A letter from the community explaining all of the services we can and do provide, and an overview of the living environment where the resident resides;
- Demographic and insurance information;
- A current list of medications;
- Notes on recent medical concerns.
Once the resident was stabilized in the emergency room, the ER staff planned to send the resident back to Crosby Commons later that night. The Director of Nursing called the ER physician to discuss in further detail the resident’s recent history of medical concerns, in addition to the reason sent to the hospital. A comprehensive transition of care was discussed, including the services available at the assisted living community, which was not designed for the complex level of medical problems the resident was facing at the present time. Our (and the hospital’s) relationship-centered care philosophy of treating the "whole" person guided us to work with the physician to evaluate the surrounding medical conditions while the resident was at the hospital. The physician expressed appreciation for the information provided by the Director of Nursing and decided to admit the resident for a complete workup as he then had a clearer understanding of the situation and justification for the admission.
Armed with the facts of the resident’s global situation (living environment, increasing medical problems, current medications) the physician, hospital staff and community nurse were able to create a plan to meet the resident’s complex medical needs through a short-term hospital stay, where an underlying medical condition was discovered. The hospital stay was followed by a stint at a rehabilitation facility. The resident eventually returned to the assisted living community, medically stable and with an actual increased level of independence. Without the communication between the Crosby Commons nursing staff and the emergency room team, Mrs. Smith might have been assessed, and momentarily stabilized enough to be sent back to the community, only to have repeated medical emergencies which could have resulted in a compromised health status and possible long-term skilled nursing placement. Through this focus on the Transitions of Care, Mrs. Smith was able to have her health needs accurately assessed and treated, with the end result of returning to her home and back to her baseline level of independence.
