ILNC Transition Specialist
While "Shirley" had lived at her own home for over 47 years, after a fall that resulted in a fractured hip; she was placed in a rehabilitation unit a local Nursing Home. Although Shirley did complete the "rehab" program, by the time the physical therapist discharged her, Shirley's Medicaid had been switched from short-term to long-term care, leaving her in the nursing home for another year! The first day ILNC's Transition Specialist (TS) visited her, Shirley was so happy to see someone from Independent Living, she blurted out, “Are you here to get me outta here?”
As her job is to line up home-based services for the participant to ensure a safe discharge into the community, the TS worked closely with the social worker at the nursing home and her son to identify her needs, her abilities and disabilities. Despite the physical therapy, Shirley's mobility had declined since her fall: she could walk for brief periods with a walker, but not continue for a long distance. The physical therapist was concerned about the stairs she would have to climb to enter her home; but because Shirley had not lost all her mobility, she did not qualify to have a ramp installed through Medicaid. After weeks of exploring options with the TS for getting a ramp installed at her own expense, Shirley suggested taking the lift chair she already had in her home and re-installing it in the rear entrance.
Our TS then worked on other supports for community life: picking a managed long-term care plan, signing up for Meals on Wheels, arranging transportation, exploring adult day centers and other informal supports. All the services she required were in place for the Discharge Plan Meeting, and Shirley was home in time to celebrate Easter Sunday with her family. Every time she sees her, Shirley still thanks our TS for helping her get out of that nursing home.