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Coordinating Care to Ease a Mother’s Burden

My story highlights care coordination in patient with several complex medical conditions. My patient has cerebral palsy, epilepsy, history of brain injury at birth, and history of stroke as a child. After a recent hospitalization he began experiencing some alarming weight loss and deconditioning. His mother is his primary caregiver and she was at her “wit’s end” in communicating with his specialists to figure out what was happening. I began working with the mother, helping the communication with the specialists (sometimes just ensuring the labs were sent to them in time for the office visits). I worked closely with the patient’s primary care doctor to coordinate care with specialists, labs, and physical therapy and occupational therapy. Since we began working together, his weight has improved, his mood swings are improved and he has been more alert. He has regained some of this strength, stamina, gait, and has resumed activities he enjoys. His mother expressed to the PCP that she is so pleased with our help, our “tying things together” for her.

Tags: Medical Home

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