Marie F. is a 79-year-old Hispanic female with heart failure and Parkinson's Disease. She lives alone and has no family living nearby. Marie understands English but isn't very comfortable speaking in English.
On a rainy day in April, Marie slipped in her driveway and hurt her hip. Marie was taken to the hospital and had surgery to fix her hip. The hospital social worker called Marie's daughter, Susan, who lives 400 miles away. Susan plans to come and help her mother once she gets out of the hospital. She works so she won't be able to stay more than a few days.
Susan arrives the day before Marie leaves the hospital. She is worried about how her mom will do at home. There are steps at both the front and back doors and she is nervous about how her mother will get to her doctor appointments after she has to go home. The hospital social worker connects Susan with a bilingual care coordinator.
- The care coordinator arranges to get hand rails on the front and back steps and tub. She also makes sure Marie knows how to use her walker.
- The care coordinator reviews the discharge plan with Marie and Susan. She helps schedule appointments. She makes sure Marie knows how and when to take her medications.
- The care coordinator made sure Marie's doctor had a list of all the new medicines Marie was put on in the hospital. She coordinates the follow-up care the doctor ordered.
- Susan goes home feeling comfortable that her mom is in good hands.