Helping a Patient with Over 30 Wounds Heal Safely at Home

When Mr. Franklin* was discharged to his Queens home from a skilled nursing facility earlier this year and was admitted to VNS Health Home Care, his home care team knew he would require a high level of care. Mr. Franklin was bedbound, with a rare skin condition that left him with more than 30 painful wounds in various stages of healing. He was also dealing with extreme weight and diabetes.

Mr. Franklin’s health situation was so challenging, in fact, that many health care organizations, including nursing facilities and other home care agencies, wouldn’t accept him because they couldn’t provide the level of complex care he needed. But home was where Mr. Franklin wanted to be. Not only was it his dream, but VNS Health’s wound care expertise would be able to provide the kind of intensive, ongoing treatment that his wounds needed in order to heal.  

“One Patient at a Time”

Brenda Riordan, VNS Health’s SVP of Home Health Care and Care Management Solutions and Hospice, has encouraged our Home Care team to lean into complex cases like Mr. Franklin’s that other home care organizations might pass on, focusing on “one patient at a time” and taking an innovative and creative approach to managing their care.

In Mr. Franklin’s case, that’s just what Pearline Jackson, Queens Home Care Branch Director, Naserudeen (Nas) Hassan, Mr. Franklin’s Home Care nurse, and others on the Queens Home Care team have done.

From the moment Mr. Franklin was admitted to VNS Health, Pearline believed in his goal to remain at home and, more importantly, believed her team could make it possible. “Mr. Franklin worked so hard to get himself home,” she said. “Now he needed our help to stay there.”

For Pearline, who’s been working in home health care for 25 years, that commitment and compassion resonates deeply. “Today, patients are coming out of hospitals sicker and quicker,” she notes. “When others might refer a complex case back to the hospital, we’re the patient’s last hope to remain at home. Who has the long game? We do. If not us, then who?”

Partnering to Go the Extra Mile

Because his medical needs were so complex, however, achieving Mr. Franklin’s goal of staying at home would require strategic thinking and a commitment to partnering with other healthcare organizations. Once Pearline began contacting Mr. Franklin’s existing care managers and providers at his Managed Long Term Care (MLTC) health plan (which is not a VNS Health plan) and the visiting doctor’s practice that had made the original referral, she realized that none of them fully understood how serious his condition was.

One problem was that he had limited home health aide care that covered only certain hours, when he needed round-the-clock support. He also lacked an appropriate bed for a man of his size.

Pearline worked with Mr. Franklin’s MLTC plan and his visiting doctor’s office to get him authorized for additional home health aide hours as well as other medical and nutritional support. She also arranged for regular large deliveries of wound care supplies, and secured Mr. Franklin the bariatric bed he badly needed.

Ultimately, thanks to Pearline’s efforts, Mr. Franklin’s health plan enrolled him in a special program providing 24/7 HHA coverage. “The support he had wasn’t enough for us to do our job safely, so I committed to partnering with these outside organizations and provided them a window into all his needs,” says Pearline. “If we couldn’t meet these needs, he should go back to a skilled nursing facility. But he didn’t want that—and we didn’t want it, either.”

A Positive Attitude and Team Work Creates Hope

It’s been a long health care journey for Mr. Franklin, but today his wounds are healing. Nas visits twice a week to perform the complex, two-hour-plus task of redressing his many wounds, while also ensuring that he has adequate supplies and medication on hand or on order. In addition, Nas has been guiding Mr. Franklin’s HHAs and family caregivers on how to care for him in between nursing visits. Another home care nurse, Yvesdline Laforestrie, visits once a week to round out the wound care team.

“Everyone at VNS Health teamed up to help Mr. Franklin get what he needed,” says Nas. “It takes a village, and he now has a good village behind him.”

The team also guides and supports Mr. Franklin on the lifestyle changes and self-care he needs to keep getting better. Nas, for example, has been educating him on adding more vegetables to his diet, cutting down on snacks, and closely tracking his glucose. And it’s working: Mr. Franklin is losing weight—over 150 pounds at last count—and his blood glucose numbers are in a safer range.

Along the way, the two have built a deep rapport. Nas marvels at Mr. Franklin’s positive attitude. “It is the most important thing that Mr. Franklin brings to his care,” notes Nas. “He can do it because he believes it. He’s already come a long way, and I’m confident he’ll get there.” And Mr. Franklin says about his nurse: “This guy is like family.”

Now that his wounds are healing and his support is in place, Mr. Franklin has a new goal—to begin physical therapy and get to a point where he can walk on his own into the VNS Health Queens office and personally deliver a fruit platter to the VNS Health team who’ve helped him: Nas, Pearline,Yvesdline, Roger Herr, Vice President, Regional Care Services, Queens, Karen Docket, Social Worker, and the rest of the Queens Home Care team.

“I truly believe these patients are coming to us for a reason,” says Pearline. And VNS Health Home Care is meeting that call, one complex case at a time.

* The patient’s name has been changed for privacy