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Elderly patients have unique discharge planning needs. As such, the hospital nurse and case management team may find themselves challenged to not only identify the needs of each patient, but to also address those needs when planning the patient’s discharge. In the case of Mr. Trosack, a 72-year-old widower being discharged following a total hip replacement (THR), careful assessment of his home situation needs to be completed prior to discharge to ensure his safety and continued recovery once home.
Healthcare Issues After reviewing the patient’s chart and performing interviews with the patient and his family, the case manager identifies three healthcare issues that need to be addressed on discharge. ·The patient admits he has not seen a doctor in over 10 years prior to this hospitalization. ·The patient has been diagnosed with two new health issues: hypertension and diabetes. ·He has been prescribed new medications for each new diagnosis that he will need to continue taking after discharge. ·The patient cannot identify pills he currently takes at home, stating simply that they are “vitamins” for “energy.
Importance of Healthcare Issues Each of these issues needs to be addressed to ensure Mr. Trosack’s safety and continued recovery after discharge: The patient has not seen a doctor in over 10 years prior to this hospitalization. It is important for the case worker to find out why the patient has not seen any doctors, as it may be detrimental to his well-being. For example, did he have a bad experience with a previous provider and refuses to go back? Or, has he just not felt ill? Is his reasoning ability still sound? Or, is there some confusion? Is he in denial or facing fear that has kept him from seeing someone?
If the patient is able to make sound decisions and simply has no concerns, he may do well at home. However, it may also be that he is unaware he should be seeing a physician, as “elderly patients may not report symptoms that they consider part of normal aging” (Besdine, 2009, para. 9). And, if he has had a bad experience in the past with a physician, it may have lead to a mistrust of the entire profession. If he has been refusing to see a doctor despite some concerns over the years, it could foreshadow similar situations in the future. He may not call when new problems or questions arise about is new medications.
And, as evidenced by the cabinet of unused medications in the bathroom, he has a history of poor compliance, which could further impact his health. By discussing the reasons behind his lack of preventative care, the case manager will better understand the patient’s mindset and any concerns he may have. If a previous provider’s treatment or behavior has caused a mistrust of the profession, the case manager can recommend or introduce the patient to other providers, especially those that specialize in caring for geriatrics, as these providers have specialized training in caring for the elderly.
If cost is a factor, the case manager can refer the patient to applicable programs such as food stamp programs, insurance and Medicare supplement policies, state-based programs, drug company assistance programs and more. If transportation is an issue, the case manager can refer to area agencies or senior citizen centers to utilize low-cost or volunteer-driven services that assist in transporting seniors. The patient has been newly diagnosed with hypertension and diabetes. New medical diagnoses can be scary for any individual, but with elderly patients, it can often bring about a new level of uncertainty and anxiety.
Like all patients, they have questions about the new diagnosis and prescribed medications. However, the elderly patients of today grew up in a time when medical problems were not openly discussed. And now, society often looks at senior citizens as “lesser” citizens—a source for humor and pity in the media, weaker, less productive and expected to retire as they age (Day, 2011). Because of the way in which they were raised and the beliefs of society today, elderly patients may not feel comfortable asking questions.
Knowing this, the nurse will look for additional clues from the patient’s interview as to how Mr. Trosack is feeling about his new diagnoses. During his interview with the case manager, the patient seems reluctant to accept his new diagnoses. Stating he doesn’t need any “darn” medications and doesn’t like being “disabled,” the patient also shows frustration. When a patient expresses this level of frustration and denial, there is an increased risk for lack of compliance. The need for education is greatly increased in this elderly patient.
Because he has no outward symptoms of his new diagnoses, the patient does not feel he needs the new medications. The nurse needs to help the patient understand that his medications need to be continued to help prevent future symptoms from occurring. In addition, the nurse needs to be aware of additional challenges the patient may incur. Since elderly patients have often lost several members of their family (parents, siblings, even children in some cases), they are very much aware of their own mortality. A new diagnosis can bring a new awareness of that mortality, sometimes leading to a depression.
When planning other discharge needs, the case manager needs to include these factors into her plan. Home health nurses can assist by visiting the patient at home during the week to ensure proper medication administration as well as assessing the patient for signs of depression and worsening hypertension, diabetes or depression. The patient has two new medications to continue upon discharge and cannot identify pills he currently takes at home. With the patient’s new diagnoses, he has been prescribed new medications.
He has already voiced opposition to the idea of continuing these new medications because he does not feel he needs them. Because he does not feel they are needed, he is likely to have poor compliance in taking the medications. The patient would benefit greatly from education about why the medications have been prescribed and that–with appropriate compliance–he will be more likely to remain free of symptoms. The patient being unable to state which pills he does take on a daily basis is cause for concern. Without the name of the pills, there is no way to verify its overall safety.
Furthermore, the nurse and case manager cannot be sure there are no contraindications to taking the newly prescribed medications with the pre-admission supplements. The patient’s inability to recall the name of the pills also reiterates the concerns above regarding the new medications he has been prescribed. The case manager needs to work with the patient’s nurse to ensure the patient understands the importance of maintaining a current medication list, including over-the-counter “vitamins” for “energy,” to avoid future problems when being seen for other medical concerns. The Interdisciplinary Team
For the patient’s discharge to be a success, the case manager needs to incorporate appropriate members of the healthcare team to make a discharge plan. In the case of Mr. Trosack, this interdisciplinary team needs to include the patient’s nurse, physical and occupational therapy staff, a dietician, a pharmacist, and staff from the local home health agency or public health district. Each member of the team will bring to the discharge plan a unique vision for the patient’s recovery. The nurse is familiar with the patient’s medical history, as well as his feelings regarding his new diagnoses and medications.
S/He has learned how best to communicate with the patient and worked to educate the patient on his new health problems and medications. In creating a discharge plan, the nurse will share this information with the home health nurse, include the medication and treatment regimens that are to be continued, and identify goals for the patient related to each. The physical therapist will instruct the team on the patient’s abilities and limitations in relation to the patient’s ambulation and transfers. He may visit the patient’s home to complete an evaluation of additional needs.
And, he will create an exercise regimen for the patient to continue once home and make recommendations for assistive devices that the patient may be able to use. The occupational therapist will also identify assistive devices and continued therapy needs, however, these recommendations will be in relation to the patient’s activities of daily living (ADLs) rather than ambulation. She will watch the patient get completely dressed to identify any special needs and assess risk (can the patient tie his shoes or will the laces be a fall hazard? ).
She will assess the patient’s ability to shower or bathe, looking for shortcomings or safety concerns. She may also visit the home to complete a home safety evaluation, watch the patient has he carries out his ADLs, and make recommendations for ways to alter his methods to ensure safety. The dietician will make nutritional recommendations based on the patient’s needs for adequate healing. In doing so, she will take into consideration his abilities and limitations identified by the physical and occupational therapists. The dietician may suggest menus for the patient to follow.
And, her knowledge of nutrition will allow for suggestions on easy-to-carry foods, snacks or supplements that require no refrigeration and can be stored outside the kitchen, making it easier for the patient to obtain. The pharmacist will provide the other members of the team with information related to his medication regimen. He will alert the other team members to possible side effects, adverse reactions and interactions that may occur. This information will be helpful to the other members of the team as they make their own recommendations for needs after discharge.
The dietician will nclude foods that have less chance of interacting with medications and the therapy staff will be alerted to side effects that may impact the patient’s safety. Because the patient will be homebound, he will likely be referred to home health. The staff from the home health agency or public health district will take the information from all of the team members in making their own plans for assignment and recommendations after discharge. They will perform safety evaluations of their own to identify risks for patient and staff alike. They will assign staff to the patient based on the recommendations from the nurse and therapists.
They may sign the patient up for meals-on-wheels, or a similar program, based on the recommendations of the dietician and assessments of the patient’s ability to cook and clean up as needed. They will reiterate the teaching provided by the nurse and therapists while visiting the patient and look for side effects or adverse reactions while working with the patient. In short, they will develop a complete plan of care to incorporate all of the feedback from the interdisciplinary team. Safety Assessment There are several areas of concern in regards to safety at the patient’s residence.
First, the patient requires a walker and lives on the second floor in a building with no elevator. This presents a safety issue, as well as a potential psychosocial problem. Not only will the patient be unable to safely enter his apartment without assistance; but, he will also not be able to safely leave. The patient, should he reach his apartment after discharge, would be isolated from friends and family and completely homebound. He would not be able to assist in the bakery located downstairs; instead, becoming dependant on his brother to maintain the business.
Additionally, the family members interviewed by the case manager share concerns about the patient’s safety once inside his apartment, due to the small and cluttered environment. They worry that the apartment is too cluttered with memorabilia from World War II for him to safely ambulate with a walker. Per the safety assessment, there are also several rugs throughout the space. Each rug represents a trip hazard and should be removed from the environment prior to the patient’s discharge home. Additionally, there are no safety devices in the bathroom. While these devices can be installed, the patient is at risk until the installation is complete.
And, until the devices are installed, the patient cannot be assessed by the occupational therapist to ensure safe use. With the safety issues present in his current apartment, it is unlikely the patient will continue to improve in this environment. Not only is he at a high risk for fall and injury in this apartment, but his mobility will also be greatly limited by the crowded environment, reducing his physical activity. Such limitation would reduce the patient’s physical improvement, which is vital in recovery from a total hip replacement. Discharge Planning Needs Per the family interview, there is a lack of support available to the patient.
For any patient to recovery successfully after discharge from the inpatient setting, they must have adequate support from friends and family. Elderly patients are especially reliant on adequate support, as they are more likely to experience a functional decline from baseline in the two weeks following a hospital discharge (Naylor et al. , 1994). Mr. Trosack has a brother and a married middle-aged son. Mr. Trosack co-owns the bakery with his brother, who is now running the bakery on his own. His son is somewhat estranged due to a difference in religious beliefs, has a young family of his own, and works nearly 60 hours a week, as does his wife.
None of the people closest to Mr. Trosack can make him a priority in their lives. During the family interview, the case manager learns that they were planning on taking turns assisting the patient in his home. However, their busy lifestyles leave little time for that and they do not want to bring in outside assistance. Further, the family does not seem to understand the importance of regular medication administration in addition to denying the two new medical conditions exist since the patient has shown no outward symptoms of being sick.
Their answer to cleaning up the apartment is throwing away some of the patient’s most treasured items. Rather than asking for suggestions in making the apartment safer, the family would prefer to have Mr. Trosack dispose of his memorabilia from World War II. This, combined with the social isolation brought on by being homebound and unable to participate in his long-time business, would worsen his chances of developing depression. Should the patient develop depression, his recovery would be further impacted by lack of compliance with medications (Carney, Freedland, Eisen, Rich, & Jaffe, 1995).
Further, depression can lead to elderly patients becoming confused or forgetful, eating less, poor hygiene, and becoming further isolated from friends and family (“A. D. A. M. Medical Encyclopedia,” n. d. ), all of which would further delay a complete recovery. Social Isolation & Psychological Factors With the patient’s physical limitations, if he were to discharge to his apartment, he would be isolated from the outside world. Because he still relies on a walker, he would be unable to climb or descend the stairs and unable to participate in his own bakery business.
He would also rely on visitors for his groceries, trash removal as well as any social interaction. Despite the fact that family members are physically close to his apartment, the relationships are strained and their schedules do not allow for him to become a priority in their lives. When patients are socially isolated, they tend to do poorly. Not only do socially isolated people tend to become anxious and depressed, but they are also more likely to develop high blood pressure. Additionally, isolation has been significantly correlated both with an extended wound-healing time (Cacioppo & Hawkley, 2003).
Despite the length of time the patient has been in the hospital setting, he is still recovering and his body is still healing. The patient needs to be in an environment that promotes healing. Furthermore, isolation has also been shown to cause impaired vision and hearing, which could increase the likelihood of fall and injury in the patient’s cluttered apartment (Frintner, 2008) In addition to the health-related dangers of social isolation, there are emotional reactions to isolation that one should consider when planning Mr. Trosack’s discharge. Isolation and loneliness not only affect the body’s immune and cardiovascular systems, but it can also lead to sleep disturbances and depression (Marano, 2003). Depression makes social interactions difficult and sometimes even stressful, causing the depressed person to withdraw from family and friends even more. And, with the patient being unable to fulfill his duties at his family-owned business, the likelihood of developing depression increases, due to a reduced sense of purpose (Smith, Robinson, & Segal, 2011).
The patient’s risk for isolation upon discharge home indicates that the patient may do better in another setting. Recommendation Upon review of Mr. Trosack’s chart, interviews with the patient and family and the safety assessment performed, it is the recommendation of this writer that the patient not be discharged home. This recommendation would be different if the patient lived on a first-floor apartment or had access to an elevator. However, given the safety and isolation issues present in his home, the patient would be better served in an assisted living facility.
Because the patient does not need skilled nursing care, and can perform his most of his ADLs, the patient does not require nursing home placement. An assisted living facility would allow the patient to have some independence in regards to his individual space and performing his ADLs while ensuring the patient a safe environment. An assisted living facility allows for monitoring of the patient overall wellness and general health and can coordinate medication administration and monitor compliance (Maryland State Bar Association, 1998).
The services provided by the assisted living facility would help to ensure that the patient stays safe by keeping a watchful eye on the patient—routine safety checks are performed and fall risks are identified and corrected as needed. The facility can also monitor his overall health through the routine safety checks as well as monitor his medication compliance, ensuring the patient takes his medications as scheduled. Furthermore, several facilities offer social activities, which would increase the patient’s likelihood of continued physical activity and reduce the risk of depression and decline after discharge.