1. Millefoglie, Mia MA

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Joe bounded down the stairs to greet us at the door "Come in and sit down as I have a story to tell you." Knowing a bit about his recent medical history and the fact that he was given 6 weeks to live, we were surprised to meet such an energetic and fit-looking man. We sat with Joe in a sunny room filled with family photos. The oxygen tank sat abandoned in the corner. With prompting, he shared a personal and medical journey that began when his wife Kathy and daughters decided to move from Virginia to Maine to join Joe's 79-year-old mother and extended family.


Joe shook his head in disbelief and said, "it's moving day, the van is packed, I got permission to work from Maine and we get a notice that my company is shutting down!" With no other options, the family moved ahead determined to find work and build a new life. Then barely settled into their new home, a whirlwind of medical events unfold. Joe was feeling fatigued with severe shortness of breath. Reluctantly, he went to the hospital and tests revealed two "silent" heart attacks and a stroke! Joe underwent quintuple bypass surgery only to face a discouraging outcome that his heart was simply not pumping sufficient blood. Transfers to multiple Boston hospitals and consultations with specialists only confirmed disappointing news. Joe was not a candidate for a mechanical implant or heart transplant; instead, he was gently advised to go home and put things in order.


Joe was sent home to a loving family with support from HomeHealth Visiting Nurses. Under the direction of Dr. Esther Shao, Joe was placed on 24-hour oxygen, a walker, and continual intravenous (IV) medication. The team developed a care plan that coordinated nursing, physical therapy, and constant monitoring by our telehealth nurse Amy Blais. With the telehealth unit by his side, Joe was taught to answer questions about his health and to submit daily vital signs. Telehealth proved to be a great tool for taking proactive steps in Joe's care. Amy monitored his status and promptly alerted his nurse Kim Rexrode about any changes in Joe's condition that would warrant medication changes or physician consultations. Dr. Shao, a strong patient advocate, was always available for medical advice, encouragement, and support to both the family and the care team. His wife Kathy learned to be a caregiver but even more importantly she didn't give up. Together they forged ahead with Joe's new motto, "I am going live my life the way I want!"


And miracles happened. Within months, Joe was stronger and no longer needed oxygen or the walker. The day we met Joe, his nurse Kim visited and was greeted with hugs from three generations of family members. She removed his peripherally inserted central line as Joe no longer needed IV medications; but she assured him that our team will continue to monitor his condition. When asked what's next... he grinned and his blue eyes sparkled, "I am going to get a job!"


As Dr. Shao said: "Joe's story is a great example of the success that can be achieved through the collaboration of physicians and home health agencies. He was still quite ill after returning home, requiring oxygen, taking numerous medications, and was placed on strict dietary restrictions. The nurses and therapists stepped right in and were acutely aware of all of the challenges he and his family were facing. Their day-to-day observations and communications with us about his progress were critical in helping all of us get him to where he is today. Ultimately this collaboration allowed him to be at home and spend time with his family over the past year, which as we know, is priceless."