By Jane A Malkoff MSN RN NP
Ruthie did not have any relatives living nearby and the relatives she did have were busy with their own lives and plans. Moving to live near them would not help with the challenges she was facing with her own needs. She had been in and out of the hospital and in and out of rehabilitation facilities. She just did not feel up to par with her strength and capacity to manage at home on her own.
After a rehabilitation stay Ruthie decided to try remaining at the facility to determine if staying there long-term would be best for her. As time went on, she did not get any better and even felt like she was declining further. She spoke to her elder law attorney who gave her Clarity Care Givers, LLC information. Ruthie called to obtain details about how to decide if she could go home again. The following questions were covered with Ruthie and her out of town Health Care Power of Attorney. They then addressed the questions during a Care Plan Meeting at the nursing facility.
- Do care needs require the availability of a licensed nurse 24/7?
- Can the current nursing functions such as any medication set-ups, wound care treatments, oxygen needs, or laboratory tests be managed at home?
- Is there a need for more than one person to assist with mobility?
- Can the home be compatible for home care with such things as wheelchair accessibility, good repair, safety features?
- Are the number of hours of care needed compatible with the budget?
- Can a reliable licensed care giving company in good-standing be found to consistently provide quality care?
- Can medical care be easily obtained by in-home provider visits or through transport to preferred provider offices?
In Ruthie’s situation it was discovered all of her care needs to be quite compatible with home based services as well as her budget. A trial of going back to her home was put into motion. Arrangements were made with Clarity Care Givers, LLC for assistance with mobility, medication reminders, meal preparation, personal hygiene, outings, light housekeeping, and companionship. She received assistance every morning for a few hours, assistance every afternoon for a few hours, and overnight assistance for ten hours. After a few weeks Ruthie was doing so well her overnight hours were reduced to 8 hours and again over time the overnight care was able to be incrementally eliminated while her daytime care continued as two four-hour blocks.
Additionally, Ruthie had these supports added to her home care plan: personal alert device, daily evening check-in call with her POA, in-home medical care, geriatric care manager RN to procure/set medications and check well-being, physical and occupational therapy, and bill pay/day to day banking by her POA.
Ruthie has remained at home thus far. She and her family know there are pros and cons to each situation and are thankful this is working and has been working for well over a year. In times of not feeling well, Ruthie has added occasional overnight care. There may even come a time when the questions covered above must be revisited and Ruthie may not be able to remain in her home throughout her life. Yet, no matter what happens, Ruthie has had this current chance to be home again in a safe, informed, and loving way.