Mr. Moreno*, 94, lived alone in an upstairs apartment. Unmarried and with no children, he was very much alone except for an elderly sister and her husband, who lived in an apartment in the same building.
After being admitted to UCLA Medical Center, Mr. Moreno’s doctor and the hospital discharge planner recommended that he be released to a Skilled Nursing Facility. Despite his frailty, Mr. Moreno refused to go because he did not want to be separated from his only remaining relatives – his sister, who was suffering from advanced stage Alzheimer’s, and her husband.
Such was Mr. Moreno’s distress, that his attending doctor and the discharge planner agreed to let him go home, but only if he had sufficient care management services to keep him safe. A Partners in Care MSSP care manager arranged to meet Mr. Moreno at his home as soon as he was discharged from the hospital so that he could have immediate access to services and oversight.
Inside his unlocked apartment – he never locked his front door because he had difficulties getting up to answer it – the MSSP care manager found Mr. Moreno sitting in a recliner, which is where he also slept. His apartment was cockroach infested. There were roaches crawling on the walls, on the kitchen table and, even worse, on him. The apartment was in complete disarray – dirty floors, dishes with rotting food in the kitchen sink and more rotting food in the refrigerator, and soiled clothing everywhere. Although very weak and clearly in desperate need of help, Mr. Moreno did not want to move from his upper floor apartment, even though he would need a gurney service to get him up and down the stairs.
he MSSP care manager conducted an Initial Psychosocial Assessment, where she learned that Mr. Moreno had no caregiver, no food in his home, and no way of getting food – except periodic help from his elderly brother in law. In addition, Mr. Moreno was also legally blind, hard of hearing, and could hardly move. He had a urinal that he kept nearby – but had no one to empty it. A visiting registered nurse discovered that he had a fever and his vitals were out of normal range. The nurse called his doctor and arranged for him to be readmitted to the hospital.
With Mr. Moreno’s agreement, the MSSP care manager arranged for pest extermination, and a cleaning service to deep clean his apartment and do laundry. Once he was released from the hospital, MSSP paid for an in-home caregiver while he waited to be evaluated for in-home support services (IHSS), organized home delivered meals, arranged for a visiting physician and provided gurney transportation for medical visits.
His MSSP care manager made contact at least once a month, to monitor his progress, and to ensure that his daily living needs were being met. Over time, Mr. Moreno’s condition improved to such an extent that the care manager was able to reduce visits to every three months. He continued to live safely in his apartment for another four years, passing away just a few weeks before his sister.
Mr. Moreno was very appreciative of the MSSP program and how it helped him stay at home, close to his sister. His MSSP care manager remembers him saying, “A visit from you is better than a dose of medicine.”
* Not client’s real name
