This case study series highlights successful collaborations between physician practices or health systems and senior living placement consultants that reduced hospitalizations for elderly patients and burnout in their caregivers.
The ER “Dump and Run”
In this Case Study, learn how a collaboration between Oasis Senior Advisors and an emergency room case manager found an assisted living community for a senior abandoned in the ER.
The client, “John,” a single man in his late 70s, had spent most of his adult life in a city several hundred miles away from his family. One of his friends in that city had Power of Attorney (POA) and another was his Health Care Proxy (HCP). As John’s health issues mounted, his sister, “Mary,” urged him to move back to the South Shore. He agreed to move to an assisted living community close to Mary. As part of the transition, he moved into his Mary’s one-bedroom apartment while they looked for the right place. They found an assisted living community they liked but the pre-move in assessment revealed John had significant cognitive decline. The community felt they couldn’t safely care for him and turned him down. The next step should have been to find a memory care community for him, but he didn’t have a diagnosis for cognitive decline, and he didn’t have a local doctor to make the diagnosis. In other words, traditional assisted living wouldn’t take him because of his memory and confusion issues and a memory care community wouldn’t take him because he didn’t have an appropriate diagnosis. A couple of weeks went by while they waited for a doctor’s appointment. Meanwhile, John was sleeping on Mary’s couch. He was incontinent and needed help with several activities of daily living (ADLs). Mary, who had health issues of her own, reached the end of her rope. She brought John to the ER and left. She refused to come and get him when the ER called her to pick him up. The hospital wouldn’t admit him, but they also couldn’t find a skilled nursing facility that would take him. John was not on Medicaid, and while he had some funds, couldn’t afford to private pay for long-term care at a skilled nursing facility and he didn’t need rehab (which would be covered by Medicare). Additionally, there was no availability at the skilled nursing facilities in the area that had secure units. John, confused and frightened, was stuck in the ER.
The Solution
The case manager assigned to John at the ER called me to explain the situation. I spoke with Mary to gather the details. I also called John’s POA and HCP to introduce myself and to see if they had any knowledge of a dementia diagnosis. It turned out John didn’t have a regular doctor in his old city either.
After a short search, I found a community in John’s price range that would allow him to move immediately into an apartment in traditional assisted living but go to the memory care unit during the day while they waited for a dementia diagnosis. After he got the diagnosis, he would move to an apartment in the memory care unit. I spent the next two days speaking alternately with John’s sister Mary, with one of John’s nieces, John’s cousin, John’s aunt, the POA, the HCP, and the hospital case managers (both day shift and evening shift), setting up the assessment, getting the paperwork in order, coordinating the purchase of linens and towels, and getting the niece to bring over John’s things and medications from Mary’s apartment. John finally moved to his new home after four days in the ER.
