The Scenario:
A case manager referred a client living in permanent supportive housing to HFH because they could no longer walk. According to the patient, the police broke both of his legs, and he was sent home with crutches and no follow up plan.
The Problem:
The patient was in extremis and unable to bear weight in either leg. He also lacked any access to pain medications. When anHFH nurse conducted the home visit, she had no way of knowing his history or where he had received care.
The Solution:
HFH initiated an inquiry with LANES so they could review the patient’s hospital records. The nurse concluded the patient had a non-displaced fracture in his right leg and was supposed to follow up with the orthopedic doctor the next day.
An in-house physical therapy evaluation showed the patient could bear weight in his left leg. A front-wheel walker was ordered, and a prescription for pain medications was called into a local pharmacy. The patient was unaware of any of this information, but the nurse was able to share it with him.
The nurse also arranged for transportation to an orthopedic appointment for the following day, set up the home PT evaluation, confirmed the arrival date of the walker, and worked with the pharmacy to deliver the patient’s pain medications.
In addition, the nurse determined who the patient had previously seen for primary care and scheduled an appointment for him to see his PCP the following week. LANES enabled the nurse to address the patient’s needs, establish safety in the home, build continuity of care, and prevent a repeat visit to the emergency room.
