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The Client was admitted for Respiratory complications, Malnutrition, Abnormal Gait & Mobility, and Sacral Pressure Ulcer. Before their discharge, the Villa Holistic Caregiver (VHC) nursing team went to the rehab facility to meet the client and do an initial onsite assessment and coordinate with the therapy and nursing team to determine what level of care they would be requiring. The client would be needing 24/7 care and they were pretty much wheelchair-bound.
After 6 weeks of VHC's holistic care, we not only prevented a re-hospitalization, but the client gained over 20 Lbs., and the physician discontinued their g-tube feeding. The client’s sacral wound had healed, they were able to ambulate with a walker from being wheelchair-bound, and their physician started weaning them off the oxygen. The client's care needs to be reduced from 24/7 care to just a few hours during the day. After 8 weeks, the client was back to their normal baseline, and we successfully discharged him from our caregiver services.
The client was admitted to Warren Barr Northshore for uncontrolled Diabetes, End-Stage Renal Disease, and Abnormalities of Gait & Mobility. Before his discharge, Villa Holistic Caregiver (VHC) nursing team went to the rehab facility to meet him and do an initial onsite assessment and coordinate with the therapy and nursing team to determine what level of care he would be requiring.
Therapy was discharging him at a moderate to extensive assist, almost needing 24/7 care, and a high risk for falls due to poor gait and mobility and would be requiring the use of a wheelchair. Nursing highlighted his uncontrolled Diabetes with episodes of hypoglycemia attacks and his increased weakness after dialysis. We then met with his wife and formulated a plan of care together. They both decided that he would be requiring 24/7 care and we agreed that we would re-evaluate every two weeks after reviewing his progress.
After working with him for over two months, VHC not only prevented him from being re-hospitalized within the 30 days of discharge from the rehab facility but his blood sugars have been regulated due to the caregiver being consistent with preparing the ordered diabetic diet and our coordination with his Physician to adjust the insulin dosage. Further, with the daily home therapy exercises, the caregiver was performing with him, he became strong enough that the home therapists graduated him from using a wheelchair to using a walker. as been rehabilitated to his normal baseline and the hours have been cut from 24/7 to only 4 hrs., on his dialysis days.
The client was admitted to Avantara Park Ridge due to a Urinary Trach Infection, Hemorrhoids, and Anemia, which had become a frequent occurrence. Before her discharge home, Villa Holistic Caregivers (VHC) nursing team went to meet and assess this client in rehab. The VHC team collaborated with the therapy and nursing team to determine how much help she would need. A caregiver was assigned to her case based on a personality match, and we provided our vitals equipment (BP machine, thermometer, and pulse-ox).
The Caregiver was instructed on early changes in condition to look out for Anemia and UTIs including weakness, dizziness, tiredness, bleeding from the hemorrhoids, etc. Every time the caregiver noticed an early change in condition, she would report to the VHC nursing team in real-time who would in turn immediately go in and conduct a thorough assessment with subsequent follow-up with the home health agency and physician. The VHC nursing team recommended to the physician for frequent lab draws to monitor hemoglobin (Hgb ), then collaborate with Lutheran General Hospital for out-patient blood transfusions whenever her Hgb would drop.
The physician was on board with this recommendation. Whenever she would start portraying early symptoms of a UTI, VHC would coordinate and determine if the diagnostic tests and subsequent treatment were done at home. Due to the VHC team providing this unique holistic care, we not only prevented her from a re-hospitalization within 30 days of discharge but she has not been re-admitted to the hospital for over 5 months. She has continued with our services more for companionship as her assigned caregiver has become one of her best friends.
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