Mr. and Mrs. H are an elderly couple, 87 and 90 respectively. When Elder Care Coordinators became involved they were living in their own home. Both were frail but neither had major health issues. Their only family member was a devoted nephew who lived out-of-state.
Our initial assessment was to provide in-home services (meals on wheels, housekeeping etc). The situation changed dramatically when Mrs.H fell and broke her hip. Mr.H was at too great a risk to remain home on his own. The ultimate plan involved arranging placement for Mrs.H through the discharge office at the hospital to a facility which could accommodate Medicare sub-acute care, retirement/assisted living care and also long term care if Mrs.H did not rebound from the surgery. With no local family available, Elder Care Coordinators was able to provide a smooth transition throughout the entire process. This was made easier by our efforts in pre-planning with the family before the crisis occurred