CMSA Today - Issue 8, 2013 - (Page 14)

CMSA Examining Your Program Where Was Care Coordination? One scenario provides reason to examine our own programs as we seek to provide the best care BY JUDITH R. SANDS, RN, BSN, MSL, CCM, CPHQ, LHRM, CPHRM T he dreaded phone call came. My husband's 79-year-old aunt was rushed to the hospital with a myocardial infarction and taken to the catheterization lab. Her 91-year-old husband, who is alert and oriented but also blind and morbidly obese, was home alone! His primary caregiver, my husband's aunt, delayed calling EMS since she would not leave her husband home alone. The immediate need was to locate caregivers for him since my husband and I live 800 miles and a two-hour plane ride away. Fortunately, we already had a relationship with an agency that came to the rescue and had caregivers in place within three hours. The challenge was clear: these well-educated individuals had no children, had not prepared any advance directives, and truly believed that they did not need to do any advanced planning. They strongly believed that if there was going to be a medical crisis, it would be with the husband and not the wife. The ICU nurses were great at providing key pieces of information, thus making us feel her clinical needs were being addressed. However, many of our requests went unaddressed while she was still in the ICU and still alert and oriented, such as having case managers speak to her and ascertain her wishes, as well as completing the advance directive document prior to our arrival. This need was also shared with the ICU nurses. The initial case manager had left the booklet at the bedside, yet no attempt was made to have it completed. Had her condition changed, there was a high probability that her wishes would not have been known or respected. Once on the scene, some 30 hours after the initial call, we made this the first item of business, luckily while she was still alert, oriented, and able to express her wishes. 14 CMSA TODAY Issue 8 * 2013 Lack of communication from the various medical practitioners involved became very challenging and disturbing. The cardiologist was a master at evading the notes on the front of the chart, requests on the white board, and notes from the nurses to contact the family. He was a magician at not being visible when we visited at various times of the day. With calls to administration and interventions from critical care leadership staff, the cardiologist finally contacted the Health Care Power of Attorney (HCPA). All of this did little to instill confidence in us and other family members that the care of my husband's aunt was well coordinated. While in the ICU, we requested to meet with her case manager. A second case manager told us, "It's Friday. I have a lot of weekend preparations to make, and your loved one won't be leaving over the weekend, so I will leave a facility list in the room." She was quick to state that she was filling in for the day and someone else would take over for her. The next communication came nine days later on Sunday morning; a third case manager wanted to know our rehab preferences. I shared that the list had acute rehab options circled for us to choose from and gave her our list of preferences. There was no discussion as to the appropriateness of this level of care placement or comments reflecting a re-evaluation of needs that occurred over the last eight days. Her final comments were, "Someone will follow-up with you tomorrow." A fourth case manager came to pick up the case the next day. The revised plan was home with home health - reasonable given her condition and having a 24-hour caregiver in place. During the course of the conversation I asked for a few items of information, such as if the patient had been enrolled in a CHF program, if anyone had inquired regarding the patient's possession of a scale for daily weighs, and if she had spoken with a dietitian. The answers were not heartwarming. Their focus was on setting up the care with a home health agency and securing a rolling walker for her, but not on the broader picture of case transition or readmission prevention. Known barriers were not seen as opportunities to improve care coordination or focus on the patient's unique needs. The next day, her day of discharge, I found out that a fifth case manager had taken over! I thanked this individual and stated that I would prefer to continue speaking with the case manager who addressed her needs the previous day, since having yet another person working on her case was not in the patient's best interest. I was then transferred back to the previous case manager, who told me that the staff was assigned by unit and he could not help me. "It would be unfair to the patients I have today to take on another case," he said. I

Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2013

Where Was Care Coordination?
Preparing Patients for Their Journey Ahead

CMSA Today - Issue 8, 2013