Sara Roth was a 75 year old EverCare resident of Shadow Mountain Care Center. Sara's primary diagnosis was S/P frontotemporal craniotomy for a massive subdural hematoma. She was now essentially bedridden and as a result had pressure sores complicating her current medical status. Less than 9 months prior to her enrolling with EverCare, she had been essentially alert and dependent. Sara's family was pursuing legal interventions with her previous health care providers.

Sara's family felt isolated, tremendously frustrated and out of control prior to her enrolling in EverCare. Sue was able to help this family who had unrealistic expectations, make difficult, but informed decisions. Ultimately, Sara was able to die with compassion and dignity. The family was comforted and supported by the team during this difficult time, as their attached letter attests.

This example truly represents the unique aspects of the EverCare model in action--protecting the quality of life, and when this is no longer possible, creating the most therapeutic environment to protect life's end.

Re Ms. Sue Freeman, nurse practitioner.

Ms. KATHRYNE BARNOSKI,

DEAR MS. BARNOSKI: I write this letter to express our family's deep appreciation for all

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Prior to EverCare, our family felt alone and frustrated in dealing with all Sara's medical needs at Shadow Mountain. It was difficult reach a doctor or getting answers from her nurses regarding her condition or explanation of medications. EverCare became like a fairy godmother who orchestrated a wonderful team approach to caring for our mother. Communication between Dr. Sapp, Ms. Freeman and myself was excellent and that in itself did wonders for my peace of mind.

I would like to take this opportunity to thank one of your shining stars--Ms. Sue Freeman. What a wonderful woman! She is articulate, highly skilled, organized, professional, and has a great heart! I always felt like Sara was a top priority with Sue and for that, we will always be grateful.

EverCare works. That is important for you to know. God only knows what would have happened to Sara's quality of life without Dr. Sapp and Ms. Freeman.

Thank you from the bottom of our hearts.

Sincerely,

Rose Dealba is an 82-year old female resident of Mi Casa, patient of Dr. Greco with a history of cervical myopathy and chronic diarrhea. Mrs. Dealba was essentially bedridden and total care because of her cervical myopathy. Of note--Mrs. Dealba is cognitively intact. Her inability to care for herself had added depression to her problem list. Her quality of life was less than optimal due to her inability to get herself to the bathroom, to feed herself, etc. The patient and her family felt there was not hope for improvement in Mrs. Dealba's condition.

With slow and progressive/incremental physical therapy, occupational therapy and restorative nursing, Mrs. Dealba was able to feed herself, transfer and ambulate to the bathroom with a walker and assist of one. Her chronic diarrhea has finally been controlled. With another round of PT she has become more independent in her transfers and ability to get to the bathroom. She is now able to go outside with her family.

Both Mrs. Dealba and her family are thrilled with her progress. With Mrs. Dealba's previous medical carrier, physical therapy had been denied. She has been able to maintain these gains with assistance of the restorative nursing program.

It is very difficult to report only one success story. Team members report successes in practicing the EverCare model on a daily basis. A recent event leading to a letter of appreciation for Mary Ann Allan is one of many examples. Mary Ann has grown especially close to her residents and their families in a very short time as she joined EverCare in June of 1998.

Elizabeth DeBruler is an 89-year old resident at the Glencroft Care Center with a primary diagnosis of S/P CVA and Hypertension. Elizabeth is alert, oriented and very functional with no stroke residual. She is up and about daily in the facility ambulating with her walker. Mary Ann and Dr. Kaczar are the Primary Care Team and work together to monitor Elizabeth's blood pressure and medications.

In December, the nursing staff reported to Mary Ann that Elizabeth was confused with decreased food and fluid intakes. Mary Ann examined her, ordered a workup to rule out a treatable cause, and discussed a treatment plan with Dr. Kaczar. Labs showed a urinary tract infection and dehydration. The BUN was 56, Creatinine 2.4. A family conference was convened with Elizabeth's daughter Arlene Latham, Dr. Kaczar, Mary Ann and the nursing staff. Potential treatments were discussed and Advanced Directives were reviewed. Elizabeth's wishes were considered as well as her daughter's. Everyone agreed on a plan. Antibiotics by mouth would be started and if no improvement in food/fluid intake short term, intravenous fluids for hydration would be given. Elizabeth would remain a do not resuscitate. Intravenous fluids would be given in the care center with full support of the Director of the Nursing and the staff rather than transport to the hospital. Elizabeth did not improve with antibiotics alone and did require intravenous fluids. Mary Ann contacted the Case Manager, Rose Larkin, and it was determined that Elizabeth would qualify for Intensive Service Days for a change in condition and to prevent a hospitalization. As Elizabeth improved, she was moved into a Skilled Nursing benefit. Mary Ann visited Elizabeth daily and updated Arlene on her condition. Elizabeth recovered with the assistance and support of the family, facility staff and the primary care team.

EVERCARE,

DEAR MS. BARNOSKI: I would like to express my appreciation for the interest taken and care given to my mother, Elizabeth DeBruler by Dr. Philip Kaczar and Mary Ann Allen. Dr. Kaczar's prompt attention to her recent physical problems have been commendable and the follow-up by Mary Ann has also been impressive. The close attention and efforts to make her comfortable have been very satisfying to me.

EverCare is to be commended for their foresight in selection of these individuals. I feel they are an asset to Ever Care and Glencroft Care Center.

Sincerely,

Coming ``live'' in a new facility is always an opportunity for everyone involved; the member and family, the facility, facility staff, EverCare staff, and the primary care team. There are many reservations. ``Should I have signed my Mom up for this EverCare?'' The staff is wondering how this will work. The nurse practitioner is thinking ``how will I fit in with this group?''

One of my new members in a new facility was a 72-year-old woman. She lived there for six months, after suffering a severe CVA, leaving her aphasic, NPO with a feeding tube. She was dependent in all ADL's, and spent a good portion of her day in a geri chair, watching her soaps. She did respond by nodding her head, but it was extremely difficult to assess her level of orientation.

This member's son had a discussion with the primary care team and all of her medications, including cardiac and seizure, were discontinued, at his request. The member responded to this change, she woke up!

A team effort ensured. Physical therapy and occupational therapy screened the member and requested an evaluation. Indeed there were documented changes.

Therapy and the primary care team discussed a plan of care and put it into action. Case management became actively involved. Speech therapy came on board as the member demonstrated gains in other areas. Communication was the key to this plan.

The member worked very hard and made continual gains. She is now able to assist with bathing and grooming. She can propel her wheelchair throughout the facility and attends activities. She is able to use a pad to communicate some of her needs. She still likes her soaps. Best of all, she is no longer a tube feeder and can feed herself after set-up.

The member was not just ``the CVA.'' The office staff could visualize our member and truly felt great as she made gains.

The outcome of this team effort was an increase in the quality of life for our EverCare member.

EverCare can make a difference!

END