“This program was phenomenal.”

Janice at home her first day in the program

Sometimes journeys take an unexpected course, and for Janice, her path home from the hospital after an admission for hip surgery was anything but expected. Her daughter, Tammi, explains: “My mom had fallen on Halloween last year, and she ended up in the hospital and then spent five days in a skilled rehabilitation facility.” With spine fractures, Janice was barely out of bed and in significant discomfort, without 1:1 care. “It was a terrible experience.” 

In March, when Janice fell again, Tammi was distressed to find that this time, she’d broken a hip. “After hip surgery, they wanted her home as soon as possible,” Tammi says, recalling that the doctors explained she would do better if she could get up and moving right away. Recalling that her mom hadn’t fared well in a skilled nursing facility (SNF) before, she knew they had to make a different choice this time. 

“I was going through her chart and saw the note from Shayne,” Tammi explains. Shayne, a Recovery Care Coordinator supporting the Allegheny Health Network (AHN) Home Recovery Care Plus program, had identified her mom as a candidate for returning home with the program. “I was like, ‘oh my gosh, this is what I want.’ Because I can’t put my mom back in a skilled nursing facility and I can’t do this alone by myself.” 

Skilled nursing care at home 

AHN’s Home Recovery Care Plus program offers what is known as post-acute care in the home, providing rehabilitation services and skilled nursing care comparable to what a patient would receive in a facility, but in the comfort of a patient’s home.  

Janice and Tammi enthusiastically accepted admission to the program, and Shayne immediately got to work making sure Janice would go home with everything she needed. “I cannot believe how willing he was to do whatever he needed to do to get us whatever durable medical equipment we needed,” Tammi recalls. She also notes that he made sure her mom’s caregiving needs were arranged prior to her return home — a huge support for Janice’s care, as Tammi works full time and her mom would need weeks of care. 

“The fact that I did not have to take FMLA time, was incredible. I didn’t realize FMLA was unpaid,” Tammi shares. “The fact that I only ended up taking off two days of FMLA in total, was fantastic. I was able to go to work, and I was able to get back to the house and feel like Mom had a good day, and I could take over. 

“I actually thought she was better supervised at home than in a rehab facility.” 

Personalized care for everyday life 

Along with regular caregiver support, Tammi also observed that the in-home physical therapy (PT) and occupational therapy (OT) support made a big difference, notably because the therapists were working with Janice in her home environment. 

“It was just so great to have those therapists working in our actual house, making sure my mom was safe in the areas she was navigating. Being in our house, hearing about what my mom was doing on a regular basis and seeing our room sizes and doorways was so much more effective in terms of what we really needed.” 

Their at-home observations also helped them personalize their care recommendations for Janice, who normally lives alone. Tammi notes, “They’ve made suggestions to keep her safe, like ‘don’t wear socks in the bathroom.’ I don’t live with her, so I didn’t know those things were happening. It’s little things like that.” 

Personalized support for caregivers, too 

It wasn’t just Janice that benefitted from the support of the care available, either. Along with still being able to work full time, Tammi was thrilled to discover that as a caregiver, she had personalized support. No matter what the need was, Tammi says the team was there every step of the way. “Having them help us get her in and out of the bed the first time was very reassuring to me. I learned a lot as her primary caregiver,” she notes. They also helped her figure out what equipment was best to use in her mom’s home, something she’d had to do on her own after the last rehabilitation facility stay.  

And, when it came to setting up follow-up treatment, “Everybody made it so easy because they reached out first on my behalf. I didn’t have to call anybody, they called me first. That was very nice, because I didn’t have to go hunt it down myself.” 

An “amazing rebound” 

Within a short amount of time, Janice saw rapid improvement at home in the program. “My mom positively thrived in that situation,” Tammi recalls. “It has gotten my mom completely back on her feet.” Just 20 days into her rehabilitation, Janice asked Tammi to take her out to eat.  

“I said, ’yeah, I can go get something,’” Tammi says with a laugh. “And she said, ‘no I want to go out, I can do the steps.’ And she was so proud of herself — we got into her car, and off we went.” 

Tammi continued, “ I just think there is something to be said for sleeping in your own bed, wearing your own clothes, having company whenever you felt like it, having people that you love cook for you and make your favorite foods —  I think all of that has contributed to my mom’s amazing rebound. 

 This program was phenomenal.” 

Janice, top right, heading out for her first dinner out post-surgery (left).

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