EMS provide first aid and her primary care provider is notified.
Because Bernice has a number of chronic conditions and health needs, Bernice falls into the category of a "complex patient" and as her primary care provider is part of a Health Link, she is captured through this work. Bernice's primary care provider discussed the creation of a coordinated care plan with her and as part of Bernice's care plan, her doctor makes a geriatric assessment referral. Bernice's children go with her to the appointment and learn how they can improve Bernice's functional ability.
Bernice attends a falls prevention program, where she makes new friends and starts going to bingo.
One day, while leaving bingo, Bernice falls on the ice and breaks her leg. She is taken to her local community hospital.
Hospital staff call the designated referral hospital and Bernice is transferred right away for surgery. Bernice's primary care provider is notified of Bernice's situation.
Following her successful surgery, Bernice is transferred back to the community hospital, where she recovers.
1 week passes
She is discharged to a transitional care program with a complete discharge plan.
1 month passes
Bernice is back at home with ongoing support to help maintain her functional ability.
To care for Bernice in her home, with access to health care in the community, will cost the health care system about $100,000 over the next five years.