Success Stories

VNSNY and Mrs. S

Mrs. S voluntarily enrolled into CHOICE FIDA Complete on June 1, 2015. Earlier this year, she was experiencing frequent hospitalizations for an infected left leg wound with her most recent admission February 26, 2016. A Skilled Nursing Facility (SNF) stay was recommended for wound care; however, Mrs. S refused placement. Because of daily wound care needs, finding a Certified Home Health Agency (CHHA) willing to accept the case was difficult. To add to the challenges, Mrs. S had a poor appetite due to poor dentition. Mr. S, her primary caregiver, was experiencing caregiver strain due to his own medical issues.

As a result of poor functional mobility and an unreliable caregiver, Mrs. S regularly missed follow-up appointments with her wound care specialist and stopped visiting her Primary Care Provider (PCP). Mr. and Mrs. S were unable to do wound care as needed. As a result, she became frequently hospitalized for infection. Mrs. S also had numerous teeth extractions but lost the contact number for her dentist and did not follow up with the fitting of her dentures, thus causing her poor appetite. The lack of nutrition only caused more delay in wound healing.

During her recent inpatient stay in the hospital for the infected wound, her FIDA care manager (CM) coordinated with the facility´s assigned care manager. Working together, the two care managers secured wound care treatment orders for three times weekly from a wound care specialist. A CHHA referral was placed and accepted.

The FIDA CM temporarily increased PCS to 7 days x 24 hours (split shift) to ensure care needs are met, and also arranged an initial visit with a home-visiting PCP upon hospital discharge. Mrs. S was evaluated within the first week of her hospital discharge and has been very satisfied with her new PCP since.

The FIDA CM continued to work with the participant and scheduled the initial outpatient visit to the wound care specialist. Mrs. S currently follows up weekly. In addition, she was referred to a new dentist in her community and is in the process of getting dentures made. The FIDA CM coordinated with the CHHA coordinator of care for a hospital bed, which the participant received this past April. The CM also offered a referral for nutritional counseling; Mrs. S stated she will think about it and notify the CM of her decision.

The FIDA CM was able to coordinate care and services so that Mrs. S could return home to the setting she felt most comfortable and happy in. She has not been hospitalized again since being discharged to her home, well over 30 days ago. During the last outreach, Mrs. S sounded very happy and expressed great appreciation for the FIDA care management services, exclaiming to her FIDA CM, "I actually have a smile on my face now."