Dec 10

It’s so good to be home

Community Transitions Staff Member

No one hopes to live in a nursing home, but sometimes circumstances result in the need for a skilled care facility. The quandary then becomes whether the move will be permanent or a steppingstone back to a home environment. Springwell RN’s and social workers have the knowledge and resources to help residents of nursing facilities identify barriers to discharge and work to overcome obstacles and assist with discharge planning.

James moved to a skilled nursing facility from a group home he loved due to a foot wound that was getting worse instead of healing. Changes in staff at the nursing home after James arrived, complications with insurance benefits for a custom-made boot and therapy program meant that James’ stay at the facility became longer and longer. James is a quiet man and not a vocal advocate for himself. A Springwell case manager became an advocate for James.

“Case managers provide a voice when people don’t know how their voice can be heard,” shares Stephanie McCluskey, Community Discharge Planner (pictured).  For James, Stephanie worked with the insurance provider, the nursing facility, and the group home to facilitate getting the custom boot approved and made. She also made sure that physical therapy would start as soon as the boot was ready. She then helped design the plan detailing everything James had to accomplish to be ready to go home, and she made arrangements for the support James would need once he was home. James happily returned to his home with a care plan to support his continued recovery from the foot wound.

For many years, Mike climbed two flights of stairs to reach his home in a rooming house. As a laborer, the rent fit his budget and was fine until an infection required this his leg be amputated above the knee. After the amputation, he went to a nursing home to recover. During this time, he continued paying his monthly rent with the hope of being able to return home. He had difficulty getting his insurance to pay for a prosthetic leg and finally paid for it himself. By then, his savings were depleted, and even with the prosthetic leg and physical therapy, Mike could not do two flights of stairs to get to his room. Mike worried that he was destined to stay in the nursing home. As a part of our Community Transitions Program, Stephanie began working with Mike as his advocate. After much searching, she found him a home in a congregate housing site that is completely accessible and lower rent than his rooming house. Mike is so grateful to be back in a home environment and is thriving.

The Springwell team of RNs and social workers initially discuss the pros and cons of leaving versus staying in a skilled care facility. When an individual wants to move back into the community, the Springwell team works to overcome discharge barriers and help them reach their goal.