Skilled Nursing Care: Case Studies

As the smallest New Hampshire skilled nursing facility, Hillsboro House has been providing short stay rehab care and skilled nursing to people from Concord to Peterborough for a decade. Our skilled nursing services include physical, occupational and speech therapies, and ongoing physician supervision and consulting pharmacists. It’s a comprehensive regimen which aims to restore maximum function and to generate an effective, ongoing care plan to stabilize chronic conditions.

• Ms. M: A focus on diabetic care management

Mrs. M came to Hillsboro House for what was anticipated to be a permanent placement.  She had been hospitalized for complications associated with diabetes that was not properly controlled; she had associated respiratory and circulatory conditions and diabetic ulcers that she was unable to properly manage at home.  Collectively her conditions severely limited her functioning and both Ms. M and her daughter agreed that nursing home placement was imminent.  At home, Ms. M was unable to accurately manage complicated medication injections – as a result, she had frequent urgent care appointments and emergency department visits as a result of unstable blood sugar levels and respiratory distress.

46 days later, Ms. M was discharged home.  She had lost more than 20 pounds, her diabetes was effectively controlled with oral medications rather than injections and syringes, her functional mobility and endurance had nearly tripled.  She had spent extensive time with a registered dietitian to better manage a diet appropriate for diabetes.  The wounds on her legs were fully healed.  Home health services remain in place for Ms. M, and her physician, instead of admitting her to the emergency department, now monitors her with home visits.

• Mrs. C: A focus on post-surgical and wound care

Mrs. C is a fixture in one of the small towns neighboring Hillsboro.  If she’s not to be found on her daily walk, she’s likely supervising the post office.  So when she came to Hillsboro House with a complex, nonhealing infection of the  surgical site following a hip replacement she was adamant that progress be brisk.  She worked with our therapists seven days a week to regain the function and stamina that she (and the rest of the town, frankly) had been accustomed to.  During this time, the progress of the infection was reversed and the surgical site responded quickly to the specialized wound care.

• Mr. G: A focus on care coordination

Mr. G was hospitalized for acute chest pain and shortness of breath.  These chronic conditions had kept him largely home bound – in fact they so limited his mobility that most of his day was confined to a single room.  It was the physicians and clinical staff at Hillsboro House who recognized, upon assimilating the medical records, that it was an adverse interaction of suppressive immunotherapy and anti-hypertensives that accounted for his weakness and chronic pain.  Mr. G now reports his only shortness of breath is associated with the near constant task of supervising his great grandchildren.