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Providing Care Across the Continuum

Magdalena Stefanek, March 10, 2017

An 81-year old woman suffering from Alzheimer’s and several other diseases will receive support from hospice thanks to great palliative care coordination at several facilities.

The patient, who was being cared for in a nursing home, was admitted to Presence St. Francis Hospital when her condition worsened. Unfortunately, shortly after her discharge she was readmitted, then discharged and admitted again.

Each time the patient was in the hospital, the palliative care team met with her and her family to help them sort out the concerns they were facing at the moment, including the need for an advance directive and establishing a reasonable care plan based on their goals.

During the patient’s third admission, the conversation turned to hospice. The patient’s son had a very informative meeting with advanced practice nurse Carol Blendowski, nurse practitioner Amy Miner (pictured, left), and social worker Jill Revivo (pictured, right). Thanks to their instruction and support, he felt comfortable and ready to discuss hospice as an appropriate plan of care for his mom.

The patient’s son was grateful for the team’s kindness and gentle education about what to expect in the future, and even said, “I am confident hospice will provide the care Mom needs, and support for the rest of us.”

After that conversation the patient was admitted to hospice then transferred back to the nursing home to cherish time with her family.