Jean is an 87-year-old woman who was admitted to Manchester Community Hospital, in Manchester, New Hampshire, after having a debilitating stroke that
paralyzed the left half of her body. She is a widow, and her three adult children live in different states. She needs assistance eating, transferring to her
wheelchair, and most other activities of daily living. Her medical issues related to the stroke are quickly being resolved, and it is time to begin assessing her
needs for discharge and post-discharge. It is important to note that Jean’s savings have been totally depleted and her medical bills are mounting since her
healthcare insurance has proven to be inadequate to cover her medical expenses. Her limited pension and social security barely covered her living expenses
prior to her stroke and are unlikely to cover the escalating expenses that she will undoubtedly encounter based on her medical condition. Moreover, Jean has
been clinically diagnosed with PTSD after being raped by a neighbor in her home two years ago. She is still grappling with the effects of the trauma, even as the
criminal case against the perpetrator slowly moves forward. Although her family modified the home to make it more secure and less vulnerable to intrusion, her
current lack of mobility is weighing heavily on her psychologically. Despite her current issues, Jean derives great comfort from her faith as a devout Catholic. She
typically has a wonderful sense of humor and is highly organized, having worked as an elementary school teacher during her earlier years. She participates
regularly in the local garden club and on her neighborhood welcoming committee. She has a wide circle of friends with whom she interacts. Her children are
currently staying in Manchester to oversee her care and to contribute to the development of her post-discharge care plan. It is unclear whether any of the
children will stay on after her discharge to help care for Jean, but this seems unlikely unless considered essential by the medical team. An interdisciplinary team
is being developed to design a comprehensive plan for Jean’s post-discharge care.