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Working Together for a Common Goal

Submitted by: Shannon Hadding, Benefits Enrollment Coordinator


“E” lives with her spouse of over 30 years and they do own the home that they live in. “E”’s spouse does get SSI of $920 monthly, and “E” receives $181 per month in SSI. Neither one of them ever completed any more schooling than the 8th grade. They have no other family support other than each other and their 2 little dogs. “E” is 63 years old, and her husband “S” is 67. Currently “E” is receiving services through the Passport Program through Medicaid.

Our transitional care specialist, Annette, identified that “E” was utilizing the ER daily. She reached out to the CM, Lisa, to see if we can assist her with our transitional care services. The CM welcomed the assistance. A call was placed to “E” to schedule a visit and for 45 minutes this nurse was on the phone with her due to the amount of anxiety she had. She spent the majority of her time saying “Help me, help me, help me. Please help me.” She was very frustrated. She reports her anxiety is out of control and no one will help her. She states she had been to the hospital many times and they tell her to follow up with her psych physician. She states that no one will prescribe her more anxiety meds. A visit was made by the transitional care nurse. Upon arrival this nurse immediately noticed the condition of the outside of the home. The paint is peeling off the home with approximately 50% missing. There are soft spots on the porch and the railing is very loose all the way around the porch. “E” and her husband were sitting on the front porch upon arrival. There were 4 steps to get to up to the porch and “E” was sitting in a wheelchair. She was assessed and many questions were asked.


“E” reports that since her fall resulting in a spine fracture followed by surgery, she is unable to walk down the stairs. She is frustrated because she needs to see her doctors but is unable to exit her porch to get into transportation. She has not been able to follow up with her PCP, psych, or her back surgeon. There is no community stretcher transport to get her to her appointments. “E” has a long psych history, 8th grade education, and recently fell and broke her back resulting in surgery 1 month prior. She is w/c bound only being able to transfer herself with 3-4 steps at a time. She has COPD and is oxygen dependent. She has no smoke or carbon monoxide detectors. Her flooring is down to the sub flooring. She has no curtains. Her hot water heater is broke and she is unable to bathe. She has stitches in her back but is laying on a broken down couch almost on the floor. She has no lights/electricity in her dining room, first floor bedroom, or front porch because of faulty wiring. Her kitchen sink is leaking below. She has no shower curtain.

“E” is unable to get a hospital bed script because that requires a script and face to face with her PCP to assess need. She is unable to get out of her home to get to the appointment to get a bed. She does not have an Ipad or smart phone nor does she have internet. She is unable to complete a televisit. “E” needs psych meds but is unable to complete a face-to-face visit due to not being able to maneuver the steps to leave the home. Upon reviewing hospital notes, she has been labeled as seeking benzodiazepines due to her plea for control of her anxiety. No non-narcotic anxiety meds are prescribed at this time. She begged them to admit her and help her gain control of her anxiety but was rather given an anxiety med and discharged home via stretcher with orders to follow up outpatient with psych. There is notation that she reports not being able to get to appointments, but she is able to get to the ER.


After the home visit, the transitional care nurse reached out to supervisors, Jen Mihlbachler and Ashley Lehmkuhle, getting some direction. CM, Lisa, was able to initiate getting smoke and carbon monoxide detectors. “E” used all of her yearly home modification funds through Passport for a bathroom renovation including a walk-in shower. She is not eligible for any more funds until mid-February of 2023.


She is unable to go that long without leaving the home or attending appointments. Transitional care specialist, Annette, offered to donate a hospital bed to her but had no way to transport it to her.


The transitional care nurse reached out to benefits coordinator, Shannon, for help. Upon meeting with Shannon and explaining the situation she encouraged the transitional care nurse to call the Hopeline. At that time this nurse was put into contact with Colemans who offered telephonic visits and assistance while working on home improvements to get her seen by a psych physician and work on med management. The Benefits Coordinator and Transitional Care Nurse visited “E” home. A WOCAP application was filled out with her. She has no home-owners insurance and was encouraged to get a quote to see if Silver Birch can assist short term. She is unable to get any renovations completed by WOCAP without insurance. Colemans paperwork was completed with “E” and turned back in to Colemans that same day to quickly ger her services established. The Benefits Coordinator was able to establish a moving company paid for by Silver Birch to transport the donated hospital bed to her. Home Modifications Field Manager, Dave, was able to get us a quote quickly for a ramp install and get that purchased paid for by the Silver Birch Foundation. Shannon donated curtains to them and a shower curtain. Annette donated sheets/pillowcases to her.


Without this amazing team and the Silver Birch Foundation this would not be possible at all. This has impacted her physically, psychologically, and emotionally. She will have access to proper medical care and medications decreasing use of the ER. Her health and safety will be ensured allowing safe exit from the home in case of fire. Her pain will decrease having proper sleep arrangements. She was able to feel heard and assisted when she felt she was losing hope and didn’t know what to do. She was provided a quality of life by providing her assistance with basic human needs.

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