HCAP Nurse Case Manager Program a Success

The following is a human interest story from one of the Case Managers who felt that her skills had an effect on the lives of this couple.

"Over the summer, we had a middle-aged unemployed, but newly wed gentleman enter our facility with a CVA diagnosis and no insurance. My therapy skills were immediately put to work talking with his new wife in regards to payment for the hospital's services and providing grief support in light of their changed future together.

In addition to this added stress, the patient's wife was meeting his grown children for the first time. She was assured by one of his out-of-state sons that he would pay for any kind of rehab that his father needed. What really occurred were the children briefly visiting their father in the hospital and then unloading his house of any valuable possessions that they could find. Thus, not only the patient's health, but his assets were slipping away!

My first step in helping this couple was contacting the Social Security office to set up an appointment/interview that they would be conducting over the phone with his wife since the patient was not able to speak coherently. I also contacted Seniors and Peoples with Disabilities to advise them of the case and what I had already done. The hospital agreed to keep the patient and transfer him to the Swing Bed Program since his wife was not strong enough to care for her husband at home. I also contacted Hearthside and faxed them information on the patient as a possible placement for him to rehab once funding came through.

During the patient's stay in the Swing Bed Program, he received physical therapy, occupational therapy and speech therapy. His wife sat with him every day and helped him with his meals. During this time, I visited with her frequently to provide support and process the myriad of emotions that she was experiencing. I also had several phone conversations with Social Security in Salem who were helpful and emphatic to this patient's needs for continued and more rigorous rehab. Within what seemed like just a few weeks, our patient received his Presumptive Disability and Medicaid. The patient's stay at our facility would be reimbursed and Hearthside was ready to accept him for placement.

A one week follow-up phone call with the patient's wife (after he had been transferred to Hearthside) revealed that our patient was advancing well after his placement. His wife was grateful for the guidance and support that she had received while at the hospital. It felt good to have been a part of that process of helping them solve a difficult financial problem during a difficult life changing time."