Mrs. Flynn, a 68-year-old widow living alone in her home, was admitted to Community Medi-cal Center after she became dizzy and fell while shopping for groceries. She broke her ankle in the fall.

When interviewed by the hospital social worker, Mrs. Flynn admitted that she had not been taking her blood pressure medication on a regular basis and that her chronic obstructive pulmonary disease gave her difficulties when she would try to walk her dog in her gated community. After six days in the hospital for ankle surgery and a week in the hospital’s subacute rehabilitation unit, Mrs. Flynn was discharged home under the care of a home health agency. She was directed to take eight medications, three of which were brand new for her.

Mrs. Flynn set goals for herself to monitor her blood pressure and to be able to walk her dog ca s e st u d y: th e ca s eo f mr s. fLy n n00_McSweeney Feld (2317).indb 658/11/16 4:29 PM Dimensions of Long-Term Care Management66daily.

The goals of the hospital’s care team were to control her high blood pressure and make sure that she could walk properly.Once home, Mrs. Flynn’s condition deteriorated quickly. The home health agency did not start its visits until five days after she had returned home. Mrs. Flynn’s primary care physician was not informed that she had been hospitalized, and his practice’s electronic medical record system was not compatible with the system used by Community Medical Center.

Mrs. Flynn’s two daughters—who lived two hours away and did not have a close rela-tionship—could not coordinate how to manage her care, and her son, her primary caregiver, had to leave town on an unexpected business trip. Mrs. Flynn thus lacked transportation to her follow-up appointments, and her dog could only be walked once every two days by a neighbor in her complex. Mrs. Flynn had heard that a local community agency for seniors could drive her to appointments and get her a home-delivered meal, but she did not know whom to contact about such an arrangement. When Mrs. Flynn had returned home, she was given a list of her medications; soon, however, she was not sure which of the medications to continue taking.

She also could not afford all the medications, and she had no way of having the prescriptions filled and the medications delivered. Mrs. Flynn had limited food in her home following her hospital stay, and her son was reluctant to shop for provisions because his mother had not given him money to pay for them.Mrs. Flynn became even more confused when she received her medical bills. She had no way of knowing what costs would be covered by Medicare or by her supplemental retiree health insurance from her deceased husband’s employer.

She was also having trouble walking with the walker given to her by the hospital, and she was becoming increasingly depressed because she could not walk her dog as she had done before. Mrs. Flynn became lonely and isolated. She also became afraid to go outside for any reason, because she feared she would become dizzy and fall and end up back in the hospital.

1. Does Mrs. Flynn’s situation resemble a typical transition home for hospitalized older adults? How could better communication between hospital staff, her care providers, her primary care physician, and community-based agencies have helped? What types of services might have been contacted and utilized during the transition?

2. How could Mrs. Flynn’s children have been included in her hospitalization and discharge planning process?

3. What community-based agencies and organizations could have helped Mrs. Flynn with services during and after her transition back to the community?

4. Is Mrs. Flynn at risk for readmission to the hospital? Why or why not? MLA 8th Edition (Modern Language Assoc.) Mary Helen McSweeney-Feld. Dimensions of Long-Term Care Management: An Introduction, Second Edition. Vol. Second edition, Health Administration Press, 2017. APA 7th Edition (American Psychological Assoc.) Mary Helen McSweeney-Feld. (2017). Dimensions of Long-Term Care Management: An Introduction, Second Edition: Vol. Second edition. Health Administration Press.