Caring for the Patient and the Family


Patient Characteristics
A 91 year old female with congestive heart failure (CHF), atrial fibrillation, hypertension, anxiety and depression was referred to our team by her primary care provider (PCP) during her stay at a rehabilitation facility. She had had a recent stoke and was considered high-risk for subsequent readmission to the hospital.

Care Coordination
During her rehabilitation stay, we were in communication with her care team, received clinical updates, and worked with the team to plan her discharge and a smooth transition home.  Once home, we worked with the visiting nurses and PCP office to provide additional medication education and chronic disease management related to her CHF.  We discussed community resources and reviewed care plans from her various doctor visits.  Over a series of phone calls and face-to-face visits, we discussed her CHF warning signs and created an “Action Plan” for what to do.  Using a teach-back approach, we ensured that the patient and her family understood her plan.

We continue to monitor how the patient is doing based on condition-specific metrics and outcomes.  She has fortunately been able to remain at home and has not been to the emergency room or been admitted to the hospital. We remain available to the patient and her family as needed.