Mrs. Lally, 92 year old female who been living independently in the home. Subsequently, she was admitted for acute hospitalization with diagnosis of advancing dementia, delirium with dyhydration. After a successful short-term rehabilitation stay at skilled nursing facility she was discharged home with home care services. However, home care provider was unable to enter home related to clients dementia and behavior symptoms; requiring readmission to emergency room.
At Caring Resources, the Alzheimer’s Coach provides a personalized at-home assessment with family members of the individual diagnosed with Alzheimer’s disease and related dementias. Our program identifies additional resources, recommending environmental accommodations, training caregivers and family members to provide specialized dementia care. Our program encompasses individual caregiver education, support, guidance, care planning and appropriate referral sources to best meet the needs of the dementia client.
To conclude, Caring Resources was notified of Mrs. Lally’s readmission into the hospital. The Alzheimer’s Coach was able to develop a transition plan through the Pre-admission and Lifestyle Assessment tools, with understanding of the clients customary routines. The Alzheimer’s Coach was able to provide the following services in regards to assessment and coordination of care; with the development of the following services, the clinician was able to ease the client back into the home environment.
Plan of Care:
~Initial Assessment which included Cognitive Status and Wandering Assessment.
~Home Environment Assessment-creating Alzheimer Friendly Environment.
~Educating family and home care provider on transition plan back into the home.
~Educating family and home care provider on approaches of care.
~Ensuring family member is available with the transition of the home care provider, and easing anxiety of the client.
~Educating home care provider on customary routines, i.e. bathing, sleep and dining.
~Providing education regarding redirection, agitation and behavioral interventions.