Case Study: St. James Rehabilitation & Healthcare Center (Q2 2023)

Concierge: Ashley Valentin

Patient’s Age: 90 years old

Admission Date: 4/21/23

Discharge Date: 6/6/23

Discharged to: Assisted Living

Length of Stay: 47 days

Reason for Stay: Fall

How did this patient hear about St. James? Previous positive experiences and other loved ones stayed at St. James.


Details of Experience:

Mr.O had a fall in the bathroom at his home. When he went to the hospital, they told him he needed to go to a skilled nursing facility. Mr. O told his social worker at the hospital that the only place he wanted to go to was St. James. St. James welcomed him with open arms and set him up in the same unit and with the same physical and occupational therapist he had last time. Mr. O was grateful he had the same amazing staff who had previously cared for him.

The next morning, he had an evaluation with the occupational and physical therapists. Mr. O needed 75 percent assistance with toileting and 50 percent assistance with bed mobility and transfers. He was able to walk ten feet with 50 percent assistance. His plan was to go to an assisted living.

He spoke with his case manager about his discharge plan and his case manager Amber, who gave him pamphlets and brochures of assisted living facilities in the area. She also set him up with the tablet in the facility’s café with the website of other assisted living so he could see more photos and do virtual tours. Amber, his case manager, explained the process of picking an assisted living and what would better suit him in the long term. She explained how when he gets stronger, they would do an in-person evaluation with the assisted living of his choosing and explain what needed to be done on their end. Mr. O was thankful that his case manager was knowledgeable about the process and would be with him every step of the way.

After looking at a few assisted living and getting stronger every week, he chose a facility that will meet his new needs in the next stage of his life. He went from only walking 10 feet with 50 percent assistance to now walking over 150 ft with almost no assistance. He was delighted with how much he had overcome and how his care team found him a new home.

As he was getting ready to discharge from our facility, he stated, “I am going to my new home, but St. James is where I will always come back to. It is like a vacation home with all my family.”