Aging presents challenges. Most people have not considered the possibilities until challenges are upon them. When an older adult is in need of a hospital stay for a chronic condition, those concerns can quickly become more pressing and complicated.

Transitioning After a Hospital Stay

The transition from hospital to home is an especially risky time. A Perfect Homecoming (PH), a program between SRC and Lutheran Medical Center, was created to address this. PH provides care management, transportation, in home care, grab bar installation (or other minor home repairs), and meals to newly discharged seniors. The program offers comfort, practical solutions and individualized care. It can make the difference between feeling better and feeling fearful, delivering support for healing at home, while reducing hospital readmissions.

Recently, Lutheran identified a candidate for PH and contacted SRC. This man had no support at home and his situation was complicated. He had developmental disabilities and had been managing with some support, but his cognitive abilities had seriously declined. He’d come to the hospital this most recent time after the police found him alone at home after a fall. Care Managers at Lutheran and SRC were concerned that he wouldn’t be able to manage at home, but he was insistent that he wanted to go home. He wasn’t even sure where his key was.

It Takes an Experienced and Caring Team

The first step was to arrange transportation. PH clients appear on short notice, but SRC Transportation provided him with a ride. After being transported home, SRC Care Managers and police assisted him with getting into his locked home. The next step was to assess his situation. It did not take long to figure out that he could not safely continue to live there before some things were addressed. The man was unable to manage his own toileting and cleaning.

The house was cluttered and very unclean. There was structural damage and water leaking. Back at SRC, off-duty SRC drivers overheard care managers discussing next steps. The drivers immediately offered to help on their own time. They managed to get his phone working and heated up a meal, while a Care Manager went to get a new phone cord. With much graciousness and respect, the drivers stepped in and helped make sure the man would be safe.

Care Managers went into creative overdrive to find solutions. Outside of SRC, they were working with Adult Protective Services, police, and the man’s conservator. It also took help from staff and volunteers at SRC. Care Managers coordinated with SRC’s Adult Day Center and In-Home Care Services, so that a Personal Care Provider could meet the man at the center and help him bathe. The man also was scheduled for a home medical visit, but there was the condition of the house to consider. The SRC care manager met the medical provider at the house to make sure it happened. SRC’s Chores department initiated biohazard disposal. Adult Protective Services, insurance and the conservator started working to get structural issues fixed.

After having a full understanding of the client’s circumstances and living condition, it became clear that the client would be unable to remain in his home safely and get
all of his needs met. The SRC Care Manager acted as an advocate for the appropriate level of care, which meant a transition into a skilled nursing facility. He is still being visited by SRC Care Managers as a more permanent solution is being arranged. SRC will continue to support with biohazard clean-up and on-going friendly visitors through volunteer services.

Each Situation is Different

The PH program is so powerful and unique because it is individualized and comprehensive. Care Managers connect the disparate services and resources. They look at the whole picture – medical, social, physical. They build trust and offer respect. This is what really sets the program – and all of SRC’s services – apart. When help was needed, so many staff gave from their hearts and lived up to the true spirit of our mission. In the end, a senior in our community knew that he had help and, even more, that people truly cared.

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