Nursing Home to Assisted Living

Personal Health Communication, Transfer of Care, Coordination of Care.

Included: Family caregivers, Licensed Nursing staff, Physical & Occupational Therapists, Physicians, Home Health Agency, Acute Care Hospital, Pharmacy

Mr. F was admitted to the Nursing Home from the acute care hospital with a diagnosis of Volume Depletion, De-conditioning, Diabetes II, Hypertension, CHF, Urinary Retention. He was admitted to the Medicare program with physical and occupational therapy ordered for physical strengthening, gait and transfer training, assistance with ADL’s and to improve his balance.

Prior to his hospitalization Mr. F resided at an area Assisted Living facility. The intent upon admission was that Mr. F would return to the Assisted Living setting.

During his stay at the NH Mr. F experienced one fall, his daughter reported concern over his sleep pattern and some confusion which she indicated was also present prior to his hospitalization. He also had at least one episode of decreased O2 sats and exhibited occasional difficult behaviors with staff concern that he may attempt to transfer independently and suffer another fall.

Three weeks into his stay at the NH the family indicated a desire to have Mr. F return to his apartment at the Assisted Living Center, inspite of ongoing physical and occupational therapy and a recent episode of decreased O2 sats. The family arranged for a sister-in-law to live with him at the AL.

Upon discharge, the NH staff reviewed with the daughter, the discharge plan and faxed a copy of the discharge plan and orders to Visiting Physicians who would be providing follow up care to the patient. Medication orders were faxed to the pharmacy of choice and orders were sent to Home Health Care to continue physical and occupational therapy.

Visiting Physicians and Home Health Care were also provided with a care summary of the patient’s stay at the NH.