Sonya's Story

Sonya Byrd is a 58-year-old female admitted to GA RSVP in June 2023 following a stroke in January 2022 that affected her right side of her body resulting in physical, cognitive, and communication impairments. Sonya was on Medicaid and had received limited inpatient and outpatient rehabilitation services. She was discharged back to her elderly mothers’ home for a short time, became homeless and lost her mother.

Upon admission to the clinic, she had no coordinated medical plan of care despite the medical problems being the reasons for her stroke. Sonya was paralyzed on her left side and using an old wheelchair to get around. In addition, she had no support to assist with her dressing, grooming, medications, transportation or obtaining food.

Sonya had significant problems with effective communication due to her cognitive and speech problems. Sonya was emotionally overwhelmed with the complexities of her medical and physical issues and how to fix them. However, she was highly motivated to overcome her challenges to live a quality of life where she could be independent.

GA RSVP provided a rehab physician, PT, OT, speech therapy, counseling, peer support, nursing and intensive case management. Sonya was able to move into an accessible apartment which provided her safety off the streets and an environment where she could easily mobilize a wheelchair. With the help of the team, she learned skills for greater independence and safety in bathing, toileting, food preparation and wheelchair transfers. Equipment was provided for the home to promote safety and ease of care. A new custom lightweight wheelchair was provided through Medicaid.

The case manager was able to coordinate a team of physicians to address her numerous medical and rehab needs. With the documentation of these physicians, Sonya became eligible for further outpatient PT and OT services through a hospital-based program. These services have enhanced the initial therapy efforts provided by GA RSVP resulting in improved strength and safety. Sonya became able to walk the length of the gym with stand by assistance, transfer out of the wheelchair safely and independently, and bath with minimal assistance.

Sonya’s support within her home will be improved with the provision of personal support services through the Medicaid ICWP Waiver. A Medic Alert button is now in place allowing her to access emergency assistance if needed. With the assistance of case management, she acquired donated furniture and addressed physical modifications within the apartment. Transportation with MARTA Mobility has been coordinated which will allow transport out into the community for shopping and personal errands. Sonya now knows her medical team, receives much needed primary care and maintains a detailed schedule of her appointments.

Sonya graduated from the GA RSVP Clinic in March 2024. She achieved goals to improve her safety and independence. She is communicating more effectively and able to organize her medical/rehab appointments. Sonya wishes to pursue more community integration focusing on serving those in need around her area.