Patient Discharged Home After Seven Months
Tina's story is both tragic and all too common. A massive stroke had robbed her of much of her mobility, and with no financial resources, no medical coverage and no nearby family to help her, she had become a ward of the state.
After receiving initial care at an Alabama hospital, Tina then was transferred to a long-term acute care hospital (an LTACH that is not affiliated with Atrium Health) because she was dependent on a ventilator. She improved and could breathe on her own, but her care expenses had exhausted her medical coverage. With no coverage, the LTACH discharged her home.
A home health nurse was assigned to Tina and visited her, but quickly realized Tina was not medically able to be alone. That nurse involved the Alabama Department of Human Resources (DHR), and DHR brought her to Atrium Health Floyd Cherokee Medical Center. Tina was a patient at Cherokee Medical Center awaiting DHR and/or her insurance plan to assist in long-term placement. She wasn't getting any worse, nor was she getting better. That's when Dr. P.J. Lynn and hospital nurse practitioner Siovahn Woodall intervened.
Tina could improve, he believed, if she could receive daily, inpatient physical therapy. Physical therapy is not a regularly provided service at Cherokee Medical Center. Patients like Tina usually are transferred to a nursing home, but with no money and no medical coverage, she was languishing, unable to access the care Dr. Lynn believed could greatly improve her life.
Dr. Lynn called Karen Sablon, director of Rehabilitation Services, to look for solutions. Working with Taunya Faulkner, vice president of Performance Improvement and Missy Puckett, director of Care Coordination, the team arranged for a physician at Atrium Health Floyd to oversee her care.
With those elements in place, Tina was transferred to Atrium Health Floyd Medical Center where she worked with therapists, her nurses and her physicians where she dramatically improved. Tina was ready to live independently – at home. Because the state had been involved in her care, Tina's therapists suggested they complete a home evaluation with a DHR representative present to demonstrate that their patient could live independently at home. Once again, the Atrium Health Floyd team pulled their resources together, adding Emergency Medical Services to the team.
With the home assessment complete – after seven long months in Atrium Health hospitals, in addition to her previous hospitalizations, Tina went home.
The inpatient rehabilitation team at Atrium Health Floyd believes in big celebrations for their patients. For Tina, more than 40 of Tina's caregivers lined the hallway. Equipped with pom-pom shakers and smiles, the Atrium Health Floyd team applauded and cheered as Tina passed made her way down the hallway.
While the celebration certainly was for Tina, it was also a celebration of teamwork and expertise. Tina's advocates believed she had the potential to get better. She just needed the right people at the table, and those people were the teammates at Atrium Health Floyd.
“We connected the dots to all the different levels of service by advocating for the patient. Dr. Lynn made a call, I made a call, we all made calls to get this patient what she needed," Karen explained. “Our teamwork was effective, and now our patient is finally home."