LBJ Case Management Team
May 2018
Lbj
System
Harris Health System
Houston
,
TX
United States
Ms. Mini Daniel DNP, MSN, RN-BC, CPCM
Mr. Biju Ittan RN, MS, MSN
Ms. Sherry Plummer RN, MSN
Ms. Mia Song RN, BSN
Ms. Lori Miller O’Pry, LMSW, CCM

 

 

 

A patient was brought to LBJ Hospital from a personal care home after a stroke. The personal care home refused to take the patient back as the patient had no source of funding and needed help with activities of daily living. The LBJ Case Management team and Social Workers contacted the patient's brother and he refused to take the patient back, as the patient had been homeless and estranged from the family for many years and patient's sister and daughter were out of the country.
The patient did not have an ID, passport or visa. The LBJ Case Management Team and Social Workers tried multiple other placement options but all got denied. The LBJ Case Management Team contacted the patient's family out of the country and they were willing to take the patient back. The team contacted the consulate office and obtained the necessary documents. They went to the consulate and obtained a passport for the patient to travel. Also, they collaborated with the LBJ Administration and obtained financial assistance for a one-way flight ticket. This Team coordinated a safe travel plan for the patient. They collaborated with a friend of the patient to fly back with the patient so he could join his family. For this patient and family, The LBJ Case Management Team went above and beyond their call of duty and helped the patient to reunite with his family. The compassionate gesture and hard work of the team have allowed the patient to stay off the streets. The team had devoted a lot of time and energy to help this patient and this has touched our lives. We are grateful that we are able to work with such an excellent team whose goal is the safety of all patients.