New neighbor slipped through the cracks. What do I do?

[fiveofpeep]

I am so upset. A neighbor moved in and one of his friends was telling me that he is wheelchair bound and just got out of a SNF and has no family resources in the community or health care professionals following up.

I went over and introduced myself to him and he was very withdrawn. Apparently, he won't let his friend help him. I don't even know how he will get out of the couch to his WC, but I don't know how much function he really has as the friend of his is a lay person.

He has no one from the county or home health coming to follow up on him. How did this guy slip through the cracks? How can I help him?

I plan on establishing a rapport with him and I already told him to come and ask for help anytime. I plan to check on him every couple days to make sure he is alive and has everything he needs but I am so worried he is going to suffer a complication because of lack of help.

I understand that I don't know his level of function. All I know is what the friend told me. I also understand I don't even know if he wants help.

How can I help him? Shouldn't he qualify for some sort of follow up care? Can I contact the public health department? What can I do?

As an acute care nurse, I've never seen what happens when discharge planning fails. It is shocking to me and breaks my heart.

[Double-Helix, BSN, RN]

This is a tough situation because, as a caring individual, our natural instinct is to want to help and make everything better. But let me say this:

This is not your burden to bear.

It's nice that you want to help but this neighbor is still a compentant adult and allowed to coordinate his own care. If he is refusing help from friends, he may think he can manage just fine and likes his independence. That's his right, and he deserves to live without assistance if that's what he wants, even if others can't understand how he would manage. So let him live his life. Understand that while you want to help, you need to let this man make his own choices and not let yourself get wrapped up in worrying and caring for him.

You might mention once that if he wants to learn more abou community resources, you would be happy to help. Or anonymously drop off some pamphlets (meals on wheels, committ health services, etc.) but that should be it. Provide a little education and then let him direct his own care.

Remember you don't know the whole story. He may not have slipped through the cracks. He may be very capable of living independently, even if he doesn't look it. People can surprise you. He's not your patient, he's your neighbor, so (and I mean this with utmost kindness) his healthcare situation is none of your concern.

[caliotter3]

But I would still go and see him.

[Nurse SMS, MSN, RN]

He will be a lot more receptive to you if you just be his friend. Not a caretaker.

[*4!#6]

My uncle lives alone, has a specially designed car, and cares for 4+ cats and he is in a wheelchair, so I think it all depends.

[NurseCard, ADN]

Totally agree with the above. Truthfully, you've said nothing that makes me believe that this man may not be capable of taking care of himself. He sounds depressed, however. I agree that he may need a friend more than he needs a caregiver. Maybe drop by every now and then to check on him, let him know that you are close by if he needs anything.

Some pamphlets that you may want to leave with him:

local churches

senior citizen's center

meals on wheels (or similar)

card with local crisis hotline number

And whatever other community resources that he may be able to use.

And try not to worry TOO much; again it isn't your burden to bear.

But it is nice to try to reach out to him a bit. :redbeathe:o

[fiveofpeep]

Thanks everyone. Yeah I dont know if I made it clear. Although I am worried for him, I have no idea what his level of functioning is and I definitely don't think it would be appropriate for myself to intervene unless in an emergency. Independence is very important for patients.

I just want to know if I can refer him to someone who deals with this regularly and can follow up with him to make sure he is well taken care of. It really isn't my place.

I like the idea about meals on wheels. I was wondering more though is there like an agency for the county that follows cases like this? I really don't want to involve myself much more than to just build a neighborly rapport and refer him to other services or get them in contact with him.

Thanks :)

[fiveofpeep]

Oh and according to the friend, he can't even transfer out of the chair without assistance. When the friend left him, he was sitting in the couch and refused help to get back to his chair. That's more why I am concerned, because according to the friend he isn't able to transfer to and from the WC without assistance.

[nursel56]

How sweet of you to take an interest. I had a neighbor a bit like that, too. He had a small army of people who wanted to "help". Even if it was politely accepted I found out after a while he just pretty much wanted to be left alone. He was morbidly obese, so naturally he got a lot of advice about that.

I think your plan on establishing a rapport and keeping your antenna up for signs things might be amiss is a good idea. You know he has at least one friend, so perhaps you could get his phone number.

Perhaps the SNF tried to get him hooked up with a home health agency - maybe he declined that as well. He may appreciate your giving him space but being a willing ear to listen if he needs one. Best wishes to you.

[BlueDevil,DNP, DNP, RN]

Unless he asks for your help, I think you should mind your own business.

[tokmom, BSN, RN]

We have sent pt's home that have refused any home health, assisted living, snf, etc..Sure enough we see them back again within a few weeks. Some pts need to fail before they realize they need help.

[fiveofpeep]

Yeah that's what I figured. Maybe he refused follow up care. It sounds like he wanted to get out of the SNF at all costs--not that I blame him--so maybe he had to sign out AMA? I dont know.