Ardis had always cherished her independence, but as her chronic health conditions progressed, her prospects of staying independent were dimming. Life was becoming a cycle of hospitalizations, transitional care stays, and readmissions, yet Ardis continued to resist home health services, fearing she would lose her independence.
Ardis’s daughter, Tammy, was trying to stay on top of her mother’s medical needs, said Hilary Frank, Population Health Core Operations Director at Lifespark, “but between the demands of caregiving and coordinating care with multiple specialists—cardiologists, pulmonologists, oncologists, and wound care specialists—Tammy was under a lot of stress.”
Finally, after another health emergency landed Ardis back in the hospital, she agreed to meet with Lifespark, if only to lighten her daughter’s load.
While still in the hospital, Ardis was introduced to Lifespark Complete, a program that includes a dedicated advisor, full coordination of services, and 24-hour access to everyday support—at no additional cost to the client under select Medicare plans.
As part of the initial discovery process, a Lifespark Nurse Practitioner met with Ardis to do a thorough assessment and detailed medication review and collaborated with the larger team to develop in-home clinical interventions to stabilize Ardis’s health.
That team included the Life Manager as dedicated advisor, Home-based Geriatric Care Support Nurses (HBGC RN), Nurse Practitioners (NP), and occupational and physical therapists from Lifespark Skilled Home Health.
Beyond physical health
Stabilizing Ardis’s medical conditions was a vital first step, but it’s not the endgame. “What makes Lifespark so unique is our whole-person approach which focuses on all elements of well-being, not just physical health,” Hilary said. “Life Managers work with their clients to identify goals and desires, so they have a reason to want to stay healthy.” These goals can change over time, and often they do, Hilary said, but discovering what matters most is a basis of the Life Plan.
Ardis’s goals included going on occasional lunchtime casino trips with her daughter, becoming less socially isolated, spending more time with her brother, downsizing her belongings so her family wouldn’t have to deal with it in the future, and taking a road trip with her daughter, Tammy.
To help Ardis achieve her goals, the Life Plan also included specific action steps, like using her walking cane in her home to avoid falls and her inhaler to prevent COPD flare-ups, hosting monthly lunches for her brother and other older relatives, and getting outside (weather permitting) to plant flowers in her garden or read the paper.
Antidote to family caregiver burnout
To reduce the pressure on Tammy, the Life Manager coordinated resources, including food delivery, to help Ardis live on her own without relying solely on her daughter. But what made the biggest difference for Tammy was getting support for the coordination of care with her mother’s specialists. “Before Lifespark, my mom would get very concerned because she could see how stressed I was,” Tammy said. “Now that I’ve got people to support me, she doesn’t worry at all.”
Tammy gets regular updates from the team but is still very much involved. According to Leah Castle, one of Ardis’s home-based Geriatric Care Support nurses, family member engagement is tremendously valuable both to the team and to the senior. “Our clients still need advocates—people who are involved in their lives and willing to speak on their behalf,” she said. “Tammy knows her mom better than any of us, so she calls us at the first sign of anything concerning.”
Early intervention prevents hospitalizations
To date, the team has prevented at least four hospitalizations through early detection and treatment of acute medical issues, including three episodes of fluid overload. When the Life Manager noticed a suspicious skin growth, she and the NP coordinated with a dermatologist to remove the cancerous growth and set up aftercare.
On another occasion, Leah identified critically low potassium levels. She was able to confirm the diagnosis with in-home lab testing and work with the RN to treat Ardis safely at home. “Having Lifespark providers at our fingertips is essential to our success in the community,” Leah said. “Their availability and care—same-day diagnostic testing, med changes, telehealth visits—help us prevent acute health crises.”
As for Tammy, she’s certain her mother wouldn’t be living on her own or worse, not living at all, without Lifespark. “I never envisioned that our lives could be this good in terms of my mother’s health, her quality of life, and the support I get to support her,” Tammy said. “It’s truly been life-changing for both of us.”