Reevaluation

Case Study - Continued
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Tina receives a call from the Adult Day Care Center that Barbara did not answer her door for the van driver. Tina calls Barbara and receives no response. Tina drives to Barbara's house and let's herself in with Barbara's house key and finds Barbara on the bathroom floor.

Tina calls 911. An emergency medical team takes Barbara to the local hospital where it is determined that she has had a stroke. Tina immediately calls Mary and updates her on Barbara's condition. She acts as the local point-of-contact for Mary and her family to obtain the status on Barbara's condition.

Fortunately, the stroke was moderate, yet it left Barbara with a permanent disability. As Barbara's living situation has changed substantially with the stroke, it is evident that she can no longer continue to live at her home without 24 hour care.

Tina and Mary put into effect portions of the long term care plan they had developed a year earlier. Barbara has become eligible for placement at the nursing home they have selected. Tina revises Barbara's care plan to include the required physical therapy in a convalescent center after discharge, which also gives Tine and Mary time to move her things to her new home.

She works with Mary to smoothly transition Barbara to the assisted living facility including moving arrangements, sale of her home and local coordination of other arrangements. She counsels Barbara and the family to ease this life transition.

When Barbara is safely housed in the facility, Tina continues to visit frequently and provide a friendly face when Mary is not able to be there. Tina participates in the interdisciplinary team care planning meetings at the facility that is following Barbara's recovery. She advocates for Barbara with the nursing staff, facility management, and physicians to assure Barbara is receiving the best possible care.

Barbara seems happy and content and is adapting wonderfully to her new home. <Back