On November 9th, Care Coordinator Monique Jones spoke to one of her patients who had been dealing with back pain.

The patient had already had an x-ray with her provider, who started her on Prednisone 5mg for ten days, as well as an injection. The patient told Monique that the prescription and injection had not helped her pain. She had also been experiencing increased shortness of breath over the past month and a chronic cough. In addition to the treatment for her back, the patient was also taking a variety of other prescriptions, one of which, Gabapentin, she stated made her ‘feel not like herself’. Due to her various conditions, the patient was experiencing difficulty with daily living activities in her home. The patient’s niece frequently assisted her in the home, but had not yet been named the patient’s state caretaker and could not always be present.

Two months prior, Monique had requested a shower chair, shower rails, and blood pressure monitor, but these requested were not fulfilled by Lincare at the time due to missing scripts, though the patient did recieve a walker. Monique continued to follow-up with the patient under these conditions.

In the absence of assistive equipment, the patient’s mental well-being declined. During the November 9th check-in, Monqiue performed the PHQ9 assessment. The patient scored a 21 for severe depression after having scored a 12 in the previous month. The patient was not sleeping, experiencing lethargy, lack of interest, and difficulty concentrating. In combination with this assessment, Monique also performed a STEADI Fall Assessment, in which the patient scored a 10 as a high fall risk. Monique passed both of these assessments on to the patient’s primary care provider. The provider scheduled an immediate appointment for the patient.

The next week, Monique followed up with the patient. The patient reported that she was very happy Monique had gotten her the medical attention she needed. The provider had prescribed the patient anxiety medication, which the patient told Monique had allowed her to sleep well, save for a few minor side effects that patient promised to report to her primary care provider if they continued. The patient had also received her shower chair, shower rails, and blood pressure cuff, which greatly eased her difficulty in bathing and checking-in with Monique. The patient was very grateful and thanked Monique for her continued assistance throughout the process.