Owen was a 75-year-old male who was identified for the Spiras program because of a history of repeat emergency room visits and hospitalizations related to both COPD and a GI disorder, as well as complications with mental health disease, hypertension, and high cholesterol.

Identifying the patient’s whole-person situation

During the initial home visit with Owen, the Spiras Care team found that he was illiterate making him unable to read his pill bottles or understand the instructions given to him by his physician. Owen was very sick and frail. His blood pressure was excessively high and uncontrolled and his breathing was labored.

Coordinating a plan of care

The Spiras Care nurse practitioner commented that she was unsure if Owen would live another 3 to 6 months. Spiras began to have a discussion with Owen about end-of-life planning, but Owen commented that he was not ready to die. Spiras began to coordinate a plan of care with his primary care physician. Spiras helped Owen find different prescriptions for his heart and lung conditions that were more affordable. A plan was developed, specific for Owen, so he would know which medicines to take considering he could not read, and referrals were made for his GI condition.

Discussing end-of-life plans

Owen enjoyed two more years of quality life. When the time was right for him, Spiras again talked to him about end-of-life planning, and eventually a transfer to hospice services was made. Owen was able to pass away peacefully in his home as he wished.