“When I met Sherry and Lee, we instantly hit it off,” says Jen Rooney, a Return to Community specialist with the Senior Linkage Line® at Metropolitan Area Agency on Aging.
Sherry contracted polio at age 10 and has been in a wheelchair ever since. It never slowed her down—until recently. She got the flu, which turned into pneumonia and eventually respiratory arrest. She ended up at Bethel Care Center. Her husband, Lee—her companion, caregiver and fierce advocate—was determined to get her back home. They were up to the challenge. And when Jen got involved, she was too.
Sherry’s case had several challenging aspects but the biggest obstacle was weaning her off the ventilator. As Sherry’s care team worked to achieve that goal, Jen became an essential factor in the success. Because of a staffing change at the care center, Jen was the de-facto social worker supporting Sherry. That worked in Sherry’s favor because when she was ready to go home, Jen was able to work with her at home as well as in the center. “As a neutral third party, not associated with the nursing home, I am able to focus on making sure everyone works together,” says Jen. “I helped Sherry and Lee coordinate home health care, transportation and other services.”
The first 72 hours at home are critical. In Sherry and Lee’s case, the transition went well. “Lee was extraordinary in his ability to deal with the medical issues and solve problems along the way. Still, he very much appreciated the support I could provide in navigating the system and being sure all the players were on the same page,” says Jen.
“We lost so much independence while Sherry was at the care center,” says Lee. “It feels good to be back in our own home and being able to do what we want to do when we want to do it. Jen was a critical part of making that happen.”
The Return to Community initiative provides resources and supports to assist people in the transition back to community after a stay in a nursing home. The Return to Community specialist achieves that goal by:
- Becoming a part of the discharge planning team at the care facility
- Advocating for the consumer’s choices, autonomy and rights.
- Supporting family caregivers
- Providing options for community supports and resources
- Providing follow-up after nursing home discharge to ensure execution of the plan and to assist with any revisions.
To learn more about Return to Community at MAAA, email Diane Barr at firstname.lastname@example.org.