‘Being Home is So Much Better’

Home health helps people live independently at home with extra support from their care team.
A Home Health & Hospice patient at home

John Welsh is a local legend in Shelburne, Williston and surrounding areas in Vermont. He served as a police sergeant and a police chief in Shelburne. Then, as the founder and longtime owner of the Town Cobbler in Williston, his rare craftsmanship was valued by Vermonters for decades. At 81 years of age, Welsh is now grateful to the “souls” of others – his care team from the Adult Home Health program at UVM Health Network – Home Health & Hospice – whose support and regular visits allow him to successfully manage the challenges of living independently with chronic health conditions.

“Being at home is so much better. My stuff is here. My friends know where to find me. But, I guess sometimes I don’t realize I’m as sick as I am. This program is a great thing for people like me, who don’t quite need to be in a nursing home. We’re somewhere in between.” Welsh has been a home health patient a handful of times over the last two decades, for post-surgical wound care, and, more recently, for help managing his congestive heart failure. These days, he struggles with the effects of edema and fluid retention. That’s where his Home Health & Hospice care team comes in, comprised of caregivers skilled in nursing, physical therapy and social work, who make certain his physical, emotional, and social needs are tended to.

“They came in and evaluated things, and between Michael in Physical Therapy, Martha in Social Work, and Sierra, we put something together. I was very happy with it,” says Welsh. That “something” was a care plan that removed barriers to his recovery and considered what Welsh identified as most important to him – living at home.

Sierra Gempka, RN, has been working with Welsh for the last year. As a registered nurse with extensive experience in providing home health care, Gempka provides skilled nursing services such as medication management, wound care, nutrition guidance, weight and blood pressure checks, and ongoing education about Welsh’s health conditions. Most insurances cover skilled nursing services when ordered by a patient’s provider. The clinical assessments, care management and patient education that is offered not only help patients recover and maintain health, but very often prevent trips to the emergency department and hospitalizations.

“Right now, I’m on a lot of meds. My dining room table is covered with pill bottles,” Welsh explains. “I take five pills at night, and ten more during the day. It can get overwhelming. When you go in [for a doctor’s visit] and they just start talking in jargon, assuming you know what they’re talking about. You need someone to tell you in English,” he says.

Gempka and her colleagues on the Adult Home Health care team have helped Welsh fine-tune his diet and exercise regimen, manage his prescriptions, communicate with his doctors and so much more -- all centered on what Welsh identified as important for him. For Welsh, this meant his physical therapist outfitted him with a cane with an ice gripper and helped him develop a routine for safely getting out for car rides with others. Together, they also determined the best compression treatment to reduce the swelling in his legs. Welsh’s social worker helped him establish an account with the local transportation provider, Special Services Transportation Agency (SSTA), to ensure he was prepared in the event he ever needed a ride to an appointment. 

As the registered nurse of the care team, Gempka wrote up daily and nightly pill lists and a prescription-refill call schedule. She gave Welsh some helpful pointers and “translators” to make communication with his doctors more straightforward. According to Gempka, “It’s been a bit of a challenge to figure out how he can manage his edema independently, but his is a really good case of how several health care professionals can come together, work as a team, and provide the care and guidance the patient needs to live their fullest life.”

Still, there’s more. With Welsh’s former wife and his two children having passed away many years ago, he’s mostly on his own. His sister, who works as a nurse in Arizona, came to live with him for a while after one of his surgeries. After she moved back out west, one of his close friends took over as part-time caretaker until her own health took a turn for the worse. Fortunately for Welsh, Home Health & Hospice was able to step in and provide the care he needed to manage his chronic conditions so he could remain at home and still have touchpoints that allow him to feel connected.

Why is that important? Welsh’s gregarious nature makes it easy to wonder what he does on days when his friends can’t stop by. “I like conversation. I’ve been watching a lot of TV lately. Until I get lonesome,” and after a pause, Welsh adds, “Then, Sierra comes over.” A smile spreads over Welsh’s face, that familiar twinkle returning to his eyes, and it is clear how much visits from the care team mean to him. It’s also clear that his care team is always available when Welsh has a question about his care and feels uncertain about what to do next. That support often gives him the confidence to continue living alone, because he can manage his conditions with the extra help from his care team.

Welsh’s situation is typical for a Home Health & Hospice patient: He’s someone who can still live independently, but who needs a little bit of help with certain aspects of his health care. He still drives, he does his own cooking, dishes and laundry, and a housekeeper stops in once a month. Several friends and neighbors bring his mail from the post office, do his grocery shopping and shovel his sidewalk in winter. 

“Without that support system, I don’t know how a lot of people do it. And if it weren’t for Home Health & Hospice, I don’t know what I would have done. Probably the nursing home,” he says. His face falls a bit as he mentions friends who have left their homes and have not thrived in assisted living facilities, but then adds, “Luckily, I never got to that point.”

April Plante, RN, a clinical manager for the Adult Home Health program, says, “People often think that home health services are just what you get when you go home after a knee surgery and you have a nurse come check on you to make sure your wound is healing. But really, it’s so much more. It’s about surrounding a patient with a team of health care professionals who are focused on making sure the patient achieves the best possible outcomes.”

To learn more about Home Health & Hospice’s Adult Home Health program, visit UVMHomeHealth.org.

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