Continuity of Care
In a hospital setting, patients deserve a care team that understands their medical history and works together toward a unified plan. For stroke patients at Boone Hospital Center, that level of collaboration isn’t just the goal, it’s the standard. From the emergency department to acute care, from inpatient rehabilitation to outpatient therapy, every discipline is connected, ensuring seamless, continuous care.
At 5:30 a.m. on Jan. 13, 2025, Edgar “James” Walker woke to use the restroom. When he reached to flush the toilet, his left hand repeatedly missed the handle, bumping against it instead of pressing it down. Confused, he woke his wife, Dorthy, to tell her something felt wrong. Before he could finish speaking, his upper lip began to tingle and quickly went numb. Within seconds, the same numbness spread to his left hand.
Recognizing the urgency, Dorthy called a neighbor for help. In the frigid 20 degree morning, she drove James to the Emergency Room at Boone Hospital.
Upon arrival, James was immediately taken for a CT scan to rule out a brain bleed. With no hemorrhage detected, he was admitted to the Neurology Floor for further evaluation. An MRI confirmed he had experienced a right hemispheric stroke.
During his first physical therapy evaluation, James was able to sit, stand, and walk 200 feet. But the next morning, he woke unable to use the entire left side of his body, a common progression that can happen as stroke symptoms evolve.
James remained on the Neurology Floor for eight days, receiving interdisciplinary care from Nursing, Physical Therapy, Occupational Therapy, and Speech Therapy. The team noted the increased weakness and identified James as a high fall risk. They recommended continued therapy at an inpatient rehabilitation unit.
“Research shows that early, intensive therapy helps the brain form new pathways and work around damaged areas,” explains Suzy Crowley, BSN, RN, CRRN, Inpatient Rehab Manager. “The medical director for inpatient rehab is also a neurologist who frequently treats patients on the Neuro Floor, providing expert oversight and continuity throughout the patients’ hospital stay.”
James met the criteria for Inpatient Rehab and was transferred. Once on the inpatient rehabilitation unit, James’ care team assembled to discuss his needs. Each discipline set a care plan keeping in mind James’ personal goal for discharge.
At admission, James was needing to be assisted by two people in multiple areas of care. James’ goal was to be able to move with the assistance of one person.
James stayed on inpatient rehab for 30 days. Upon discharge, James was able to walk 15 feet with a walker, aided by a second person for safety. Most of his goals were met with the aid of one person assisting.
Meeting this goal was huge for James and his family. His team determined that he had gained the maximum benefit from inpatient rehab, and he was ready to discharge home and continue his recovery through outpatient therapy.
Outpatient therapy continued working with James to rebuild the skills he needed for independence. “Outpatient therapy helped me do things I hadn’t been able to do before,” James said. “I couldn’t use the bathroom by myself. Now look at me! A year and a half later, I can take care of everything I need to: shower, shave, cut my hair, use the toilet. With no help!”
James’ journey is a testament to what coordinated, compassionate care can achieve. From the Emergency Room to the Neurology Floor, from inpatient rehabilitation to outpatient therapy, every team worked together to support his recovery. By Erin Wegner