Even When Patients Discharge, Our Job is not Over

The Phone Call, By: Betty Davis

Early one morning recently I was walking into the Agapé Rehab Post-Acute Care Center(PACC) in Rock Hill and a gentleman was sitting out front in the sun.  I always try to speak to whoever is outside and see if they need any help.  This gentleman, Mr. Summers, was very friendly, and I discovered that he was there to visit his wife Rebecca, who was a rehab patient.  He was waiting for her to finish her therapy session.  We finished up our conversation as we walked down the hall toward his wife’s room.  He was a little slow walking, but very coherent.  We went in his wife’s room and had a great conversation with him and his wife. I then learned that Mrs. Summers was set to discharge home in a couple of days, so I explained who I was and that I would be following-up with them after she completes her therapy and discharges to home.     

The next couple of days were very busy at the facility. When I got home I decided to make a few phone calls to a couple of recently discharged patients.  I usually make my follow up phone calls 48 hours after the patient discharges as this allows home health to have been in touch, lets the patient get settled in back at home, etc.  Even though it was only yesterday that Mrs. Summers discharged, I thought I would call just to check on them.  Mrs. Summers answered the phone, she sounded ok but she told me that she had fallen last night after she arrived home.  She explained she had gotten tangled up in her bed sheets and tripped. She said she was sore, but thought she was ok.  I asked her if home health had been in touch and she said yes and they were going to be back there tomorrow.  I told her I would call back the next day and I told her to make sure she tells the home health nurse what had happened.  I then asked to speak to Mr. Summers to tell him to make sure they let the nurse know about her fall, but when Mr. Summers got on the phone I knew something was wrong. He did not sound like the man I had just met a couple of days ago. 

When I hung up, I immediately called his son and told him who I was.  I explained I was following up on his mom but I thought his dad needed immediate attention. I told him I was concerned because we had a long conversation just acouple of days ago, and the conversation I had just now was very different.  Chris, the son, called me back later that evening thanking me for calling him.  He said his dad was not well and he had taken him to the emergency room but did not know what was wrong yet. 

The next morning, I called Chris to see how his father was doing.  His father was stable, but Chris told me that now his mother was not doing well and he was thinking about taking her to the ER.  I explained to Chris how she could return to our PACC for additional therapy and care without having to go back to the ER and be re-admitted to the hospital.  I had our hospital liaison immediately contact Chris and explain to him the benefits of having his mom come back to the PACC, rather than go back to the hospital, and that we were still within our 30 day window since she discharged home. 

Mrs. Summers was readmitted to the Rock Hill PACC, which meant that we did not have a patient unnecessarily re-admitted to the hospital.  I continued to communicate with Chris and once Mr. Summers was ready to be discharged from the hospital, we had a room waiting for him and he was admitted to our PACC for post-acute therapy and care.  Both Mr. and Mrs. Summers were eventually discharged to home, and Mr. Summers is currently in our outpatient Rehab and doing great.

Chris, the son,is now realizing he needs a long-term solution for his parents’ care.  He is currently working with our assisted living staff on moving his parents to one of our villa apartments at our Rock-Hill assisted living where his parents will live an independent lifestyle,but have access to the care and assistance they need.  Chris will finally have piece-of-mind that his parents are safe. 

Its amazing how one late-evening phone call has made a positive difference  in all these lives.  That’s why we are AgapéSenior. 

Rock Hill Post-Acute Care Center

Whether you need Physical Therapy…Occupational Therapy…Speech Therapy or a combination of each, you will be using the latest top of the line equipment like Biodex and Nustep. Our highly trained professional staff will help you recover FASTER from your heart attack, stroke,  hip replacement, fracture, knee replacement, fall or injury. To help you recover faster medically, our  team of doctors, nurses and practitioners are available on-site for your convenience to address changes in condition and any medical concerns. Rock Hill, Fort Mill, York, Tega Cay, Lake Wyle, S Charlotte, Lancaster, Great Falls. 803-329-6565 or 800-411-2427