Lifespark often refers to the “Roller Coaster of Health Care Crisis®” to describe an all-too-common consequence of traditional, reactive care: in and out of the hospital, back and forth to doctor appointments, on more and more medications, and a gradual loss of independence.
That’s exactly what was happening to Marcie, age 80, when she was first referred to Lifespark.
After a fall that landed her in an ambulance, the emergency room, hospital, and transitional care (TCU), Marcie was eventually discharged to Lifespark Skilled Home Health for short-term, Medicare-covered skilled nursing. For the next two months, Lifespark nurses, physical therapists, and occupational therapist helped Marcie regain her strength and stabilize her health.
After her Medicare-covered services ended, Marcie had another health episode. With no transportation or family to help out, she called an ambulance, was admitted to the hospital, and then transferred to a TCU. After several weeks, she was again discharged to Lifespark Home Health, now with an added diagnosis of atrial fibrillation, along with new medication that required weekly INR testing, and a significant decline in her cognition and memory.
On her second visit, Natalia Dolan, RN, Lifespark Skilled Home Health, could tell that Marcie wasn’t managing well on her own. “She was supposed to take her anticoagulant in the evening but was consistently missing all of her nighttime medications, and some of her morning ones as well,” Natalia said. The problem, she said, was that when Marcie would wake up in the morning, she didn’t know if it was night or day. “She was calling Lifespark several times a day, anxious and confused about her medications.”
To simplify the medication regimen, Natalia reached out to her client’s doctors and had them move all the drugs to the morning. When Marcie continued to miss meds, Natalia began making daily reminder calls. She also suggested bringing on a private-pay caregiver for additional support, but Marcie refused.
“She doesn’t want to move out of her home but is afraid of spending money on services,” said Natalia, who then asked a Lifespark social worker to see if Marcie was eligible for financial assistance. That’s when they learned that Marcie had ample savings. What she lacked was a trusted guide to help her make decisions.
From crisis to solution
It was another emergency that ultimately inspired a solution. Marcie had forgotten to turn off the stove, sending clouds of smoke through her apartment. In a panic, she called an ambulance to take her to the ER. Fortunately, with the exception of a mild cough, her health wasn’t affected, but for Natalia, this was a huge red flag.
Determined to find long-term support for her client, Natalia discovered that through Marcie’s medical insurance, she could get Lifespark COMPLETETM at no additional cost. Lifespark’s flagship program would give Marcie access to in-home primary care, weekly INRs and medication set up, and a personal Life Manager, at no additional cost. It took some convincing, but Marcie eventually agreed to give it try.
As for bringing in a private-pay caregiver, that was a tougher sell. “I explained to Marcie that if she had an aide come in once a week to help with meal prep, laundry, transportation, cleaning, and shopping, she could continue to live independently, which was what she really wanted,” Natalia said. Marcie finally relented.
Network of support
Before Marcie’s Skilled Home Health services ended, Natalia initiated the transition to Lifespark COMPLETE and Community Home Care. Knowing her client’s distrust of strangers, she attended the introductory meetings with the Life Manager, Nurse Practitioner, and in-home aide, and stayed involved for few weeks to make sure she was adapting to her new Lifespark team.
According to Life Manager Kathy Swanson, RN, Marcie made it clear from the beginning that her one goal was not to move. “I reassured her that we would do everything in our power to help her stay put,” she said.
Kathy took over medication setup and, with the help of Natalia’s rubber band reminder system, Marcie continued to take her meds as prescribed. Kathy also set up appointments with Marcie’s dentist and cardiologist, arranged transportation, and wrote out a detailed schedule that included not only her clinic appointments, but also who from Lifespark would be coming on what date and why. When Marcie fell behind on her bills, Kathy also helped her straighten out her finances.
“Marcie’s memory problems create a lot of anxiety for her, so we try to eliminate as many stressors and unknowns as possible,” she said.
Less worry, more life
Marcie loves to walk but won’t venture past the end of the block for fear of getting lost, Kathy said. So, weather permitting, whenever Kathy visits, they go for long walks together. Another bright spot in Marcie’s routine is meeting a group of friends at a nearby coffee shop every day. “That’s a really important part of her day, so I adjust my visits around her schedule,” Kathy said.
In terms of Marcie’s overall quality of life, Kathy gives a lot of credit to Vicky, her Community Home Care aide, whose presence Kathy says has helped Marcie become calmer, more trusting, and more outgoing. In addition to taking care of laundry, light housekeeping, and errands, Vicky provides easygoing companionship and encouragement. Currently, they’re going through a large glass display case in Marcie’s living room, dusting her many collectables, and generally making it feel like home.
Vicky said that the relationship they’ve developed feels special. “Maybe because Marcene doesn’t have kids of her own, she’s become like a second mom to me,” she said.
Since signing up for Lifespark COMPLETE and Community Home Care services, the most obvious change in Marcie’s life is what she hasn’t experienced—no ambulance, no ER visit, no hospitalization, no TCU stay. “Knowing that she’s got people looking out for her has really helped decrease her anxiety,” Kathy said. For Marcie, that’s been the ticket to getting off the health crisis rollercoaster and living independently.