Here is an example of how our different departments collaborate to find the optimal care solutions for our clients.
During the month of February, the Community Geriatric Nurse Program (CGN) had the opportunity to work with professionals in Kentucky and Ohio in exploring resources to meet the needs of a man who resides in the Dayton area. The CGN program received a phone call from a Social Worker at a hospital in Edgewood, Kentucky. She shared that she had a patient at the hospital and she was preparing his discharge. She related patient (age 81) was brought to the KY hospital by the police. He was found to be disoriented (denied having memory issues) and had an UTI. The patient had left his home in the Dayton area driving alone. He stopped at a gas station in the area and asked for directions and the employees called the police for him and he was then transported to the hospital. The hospital Social Worker found information about the Community Geriatric Nurse Program online at Senior Resource Connection’s web site. She requested that the Community Geriatric Nurse follow up with him and his family when they returned to Dayton.
The nurse met with the Senior Resource Connection Social Service Department and discussed making a joint visit to help more fully address the needs of the client and his family. After several attempts, the nurse was able to make contact with the client’s son. An assessment appointment was scheduled and he shared that the client was staying with family while figuring out the situation. During the CGN assessment with the client and his family, the client denied having memory issues. The client and his family attributed the confusion to the Urinary Tract Infection diagnosed at the hospital. The client shared with the nurse that he had become “fed up with everything” and “had to get away” and had gone for a drive. He said he stopped several times and asked for directions, but no one helped him until the police were called at the gas station. He said he did not know how he got to northern KY. He said that he did not feel he had any medical issues and had not seen a local doctor for 2 years. The nurse and the Social Service department provided information about numerous available services including legal aid, the local Alzheimer’s Association, transportation and medical options. The nurse stressed the need for the client to establish with a medical provider since his son shared that he istaking 5 medications but no oneknew who was approving the refills. Since the client is a veteran, the nurse provided education about possible services offered through the VA and the client and his family agreed to follow through with the help of Senior Resource Connection’s Social Service Department. In follow up, the Social Service worker shared she received a phone call from the client refusing to go to the VA because they had “killed” one of his friends by not providing the care he needed. The Social Service worker agreed she would continue to work with the client and his family to explore other medical options and resources and will coordinate with the CGN as needed. The CGN provided a follow up call to the hospital Social Worker in KY.