PEA’s Transition Specialist Supervisor collaborated with the Case Management Director regarding a patient being treated for urinary retention. The Case Manager shared that this gentleman would need to discharge with an indwelling urinary catheter in place.  The concern was that the patient was homeless and therefore put him at significant risk for noncompliance and readmission.  Case Management and the Transition Specialist collaborated with local resources to see if there was any temporary housing available. The Case Management Director also explained that this patient would have a lot of medications needed upon his transition out of the hospital. The Transition Specialist (TS) listened to the Case Management Director and explained that she would connect with local partners to see if there were any available funds to keep this gentleman safe, at least until his foley removal appointment. While the supervisor worked on temporary housing with local entities, the TS in his unit arranged for all his medications to be brought to his bedside prior to his discharge. The TS also scheduled the patient for his foley removal appointment as well as a no-cost follow up appointment at the Hope Clinic and round- trip Lyft rides to the clinic and back.

In addition, the TS consulted our partners in the community paramedicine team. They agreed to see the patient daily to check the patient’s foley and ensure proper hygiene, along with medication adherence. Interfaith Emergency services also explained to the supervisor that they would sit with the patient and assist him with getting social security benefits along with other assistance he might qualify for. This is a fabulous example of a community truly working together to assist a patient, not only while in the hospital but to also ensure the patient has the tools necessary to succeed moving forward! 

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