The HeartBeat of Case Management Advocacy—Our Most Important Role Mindy Owen, RN, CRRN, CCM
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94-year-old woman has fallen, fractured her hip, and is at home in pain, hoping and expecting that with rest she will get better. She has no reason not to believe that this course of treatment (rest and ibuprofen) will work, as it has always worked before. She has never been in a hospital as a patient (except to have her children 60+ years ago) and is taking vitamins as her only medication. Prior to the fall, she was bowling 2 times a week (she has cut back from three leagues) and is active in her community as well as managing the family farm. After a couple of days at home … pain increasing, unable to accomplish activities of daily living, virtually impossible to move without help, and debilitating pain, she was taken to the emergency department of her community hospital where she was diagnosed with a hip fracture needing a surgical repair. The medical team thought that she was confused and unable to give an accurate medical history as her answers were: No, I do not have any chronic conditions. No, I am not on any medications, except my vitamins. Yes, I live alone in a four-bedroom home and climb stairs to my bedroom twice a day, and to the basement to do laundry several times a week.
When her daughter was asked to confirm these answers, she said, “all true.” She is a vibrant, active The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Mindy Owen at: [email protected]. Teri Treiger at: [email protected]. Address correspondence to Mindy Owen, RN, CRRN, CCM, Phoenix Healthcare Associates LLC, 4613 Coral Springs, FL 33067. The author reports no conflicts of interest. DOI: 10.1097/NCM.0000000000000010
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Dorothy Rute, with author Mindy Owen, and her son Larry Rute, and daughter Victoria Rute.
individual who is capable of full decision-making and has been a strong, independent woman during her entire life. The physicians and hospital team designed a treatment plan that included surgical repair of her hip and then placement in the skilled nursing facility (SNF) in her community. They also placed her on a narcotic postsurgery. The narcotic resulted in confusion, yet did not relieve the pain as well as nonnarcotic pain medication. We asked that she be given only nonnarcotics, as her system had never had anything like this before, and the reaction scared her. When we had this discussion with the team asking why they were insisting on narcotic medication, initially the response was “because that is what is ‘standard’ for any post-surgical patient.” It took several discussions to relay our request, and in fact, upon discharge she was again given prescriptions for narcotics. Not having a good understanding of the prescriptions, and
Professional Case Management Vol. 19/No. 1
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PCMv19n1-HeartBeat.indd 52
11/21/13 12:24 AM
The HeartBeat of Case Management being given them by the medical team, she felt that it was a requirement to have them filled. That is one of the examples that raised my concern; the patient I am writing about is my Aunt Dorothy. She has been traveling, bowling, managing the family farm, and contributing to her community for as long as I can remember, as well as hosting all the family gatherings in her home. I asked the team if they had discussed the plan with her and the response was that they would when they felt the time was right. I asked if there would be choices for her to choose from. Could we plan for her to go home with care in the home versus an SNF? The answer initially was, she is 94 and we always send patients to the SNF at that age, following a surgical intervention, “She will do fine.” “Fine.” What does that mean? Is “fine” the fact that she will live out her days in the nursing facility? Is “fine” the fact that it is the standard plan and therefore easiest to implement? Is “fine” the fact that when presented to her (with no other choice) she will agree and then the healthcare team can cross the “t”s and dot the “I’s” and move on? I was concerned that the most important perspective to take into consideration, my Aunt Dorothy’s, was lost, not being considered, and that one of the most critical decisions in her transition of care was taken out of her hands. Was she compliant? Yes. Was she going to advocate for what she truly wanted? No. She was weak, in an unfamiliar environment, and yes, even my strong, competent Aunt Dorothy was intimidated. As the RN, case manager in the family, I contacted the team—with her permission—and began to paint the picture of the Aunt Dorothy we know, and what resources were available. Her daughter lives in the area and is available to assist with activities of daily living, meal preparation, and transportation. I live many states away, but offered to be on site for the first week postdischarge to coordinate home care, lifeline services, transportation, and overnight care. I agreed that we would evaluate her transition and progress after 1 week and consider if any changes needed to be made. As we discussed this plan, the team began to feel more comfortable and encouraged that she could go home, and we saw Dorothy become more engaged and grateful that she was part of the planning process—and heading home, where she wanted to be. I flew to meet my Aunt Dorothy on her day of discharge. We reviewed the transitional plan with the hospital case manager, the physician, and physical therapist.
She was weak and exhausted just getting home, but the smile on her face when she was in “her” chair in “her” home with her cat, Harry, on her lap, spoke volumes. She knew she would need to engage in her therapy plan, commit to exercises that were unfamiliar, and focus on becoming stronger and back to her independent status. Could she do it at the age of 94 years? We believed that she needed the opportunity to try. Home Health Care provided a team that assessed the home for safety, along with PT and OT services and a plan to follow, and encouraged her to set up a lifeline emergency tool in her home. This was all completed, along with an all-important beautician appointment (which she refused to cancel), within the first week of her being home. I knew then, she was on her way back to optimum health and the Aunt Dorothy that I know and love. By the end of the first week she was sleeping at night, on the first floor of her home with a reduction in pain, and increased energy in the morning. She was totally focused on mastering the stairs and getting back to her bedroom on the second floor. Surprising everyone, by the third week at home she was back to her own bedroom, upstairs with Harry. She was back into her routine and no one was happier. Why am I sharing this personal story? As a reminder, all patients are individuals, with their own history, story, goals, and choices. Our role in health care is not easy, no matter what practice setting we are in, or population we are serving. We are pulled in many directions and have many responsibilities; however, I believe that there is no greater responsibility than that of being an advocate. One, that always, no matter how difficult it is, takes time to listen to the individual, takes into consideration their goals and choices, and advocates for them with safe and realistic outcomes. As a postscript, my Aunt Dorothy turned 95 on August 13, 2013. She was at home, going out to dinner to celebrate with family and friends, no walker, no cane, managing independently all levels of her home and outside in her community. She is strong, vibrant, engaged, and choosing her path today, as she has done over the last 95 years. All she needs periodically is a little help from family, friends, and an advocate. As her niece, it is my pleasure and my honor to be that advocate and make sure that she is able to always choose her path. Happy Birthday Aunt Dorothy … and wishing you many more independent birthdays to come!
Mindy Owen, RN, CRRN, CCM, a Charter Board member and Past President of CMSA and Past Chair and Commissioner of CCMC. She is the Principal of Phoenix Healthcare Associates LLC, Coral Springs, Florida, specializing in case management education and management. Her career in health care has included critical care neurosurgery and rehabilitation. She helped design and implement an SCI-TBI rehabilitation department at Wesley Regional Medical Center in Wichita, Kansas. She was the 1st Midwest Regional Director of C.M. for Intracorp and has developed and directed both acute and MCO CM/DM programs nationwide.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PCMv19n1-HeartBeat.indd 53
11/21/13 12:24 AM
A
94-year-old woman has fallen, fractured her hip, and is at home in pain, hoping and expecting that with rest she will get better. She has no reason not to believe that this course of treatment (rest and ibuprofen) will work, as it has always worked before. She has never been in a hospital as a patient (except to have her children 60+ years ago) and is taking vitamins as her only medication. Prior to the fall, she was bowling 2 times a week (she has cut back from three leagues) and is active in her community as well as managing the family farm. After a couple of days at home … pain increasing, unable to accomplish activities of daily living, virtually impossible to move without help, and debilitating pain, she was taken to the emergency department of her community hospital where she was diagnosed with a hip fracture needing a surgical repair. The medical team thought that she was confused and unable to give an accurate medical history as her answers were: No, I do not have any chronic conditions. No, I am not on any medications, except my vitamins. Yes, I live alone in a four-bedroom home and climb stairs to my bedroom twice a day, and to the basement to do laundry several times a week.
When her daughter was asked to confirm these answers, she said, “all true.” She is a vibrant, active The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Mindy Owen at: [email protected]. Teri Treiger at: [email protected]. Address correspondence to Mindy Owen, RN, CRRN, CCM, Phoenix Healthcare Associates LLC, 4613 Coral Springs, FL 33067. The author reports no conflicts of interest. DOI: 10.1097/NCM.0000000000000010
52
Dorothy Rute, with author Mindy Owen, and her son Larry Rute, and daughter Victoria Rute.
individual who is capable of full decision-making and has been a strong, independent woman during her entire life. The physicians and hospital team designed a treatment plan that included surgical repair of her hip and then placement in the skilled nursing facility (SNF) in her community. They also placed her on a narcotic postsurgery. The narcotic resulted in confusion, yet did not relieve the pain as well as nonnarcotic pain medication. We asked that she be given only nonnarcotics, as her system had never had anything like this before, and the reaction scared her. When we had this discussion with the team asking why they were insisting on narcotic medication, initially the response was “because that is what is ‘standard’ for any post-surgical patient.” It took several discussions to relay our request, and in fact, upon discharge she was again given prescriptions for narcotics. Not having a good understanding of the prescriptions, and
Professional Case Management Vol. 19/No. 1
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PCMv19n1-HeartBeat.indd 52
11/21/13 12:24 AM
The HeartBeat of Case Management being given them by the medical team, she felt that it was a requirement to have them filled. That is one of the examples that raised my concern; the patient I am writing about is my Aunt Dorothy. She has been traveling, bowling, managing the family farm, and contributing to her community for as long as I can remember, as well as hosting all the family gatherings in her home. I asked the team if they had discussed the plan with her and the response was that they would when they felt the time was right. I asked if there would be choices for her to choose from. Could we plan for her to go home with care in the home versus an SNF? The answer initially was, she is 94 and we always send patients to the SNF at that age, following a surgical intervention, “She will do fine.” “Fine.” What does that mean? Is “fine” the fact that she will live out her days in the nursing facility? Is “fine” the fact that it is the standard plan and therefore easiest to implement? Is “fine” the fact that when presented to her (with no other choice) she will agree and then the healthcare team can cross the “t”s and dot the “I’s” and move on? I was concerned that the most important perspective to take into consideration, my Aunt Dorothy’s, was lost, not being considered, and that one of the most critical decisions in her transition of care was taken out of her hands. Was she compliant? Yes. Was she going to advocate for what she truly wanted? No. She was weak, in an unfamiliar environment, and yes, even my strong, competent Aunt Dorothy was intimidated. As the RN, case manager in the family, I contacted the team—with her permission—and began to paint the picture of the Aunt Dorothy we know, and what resources were available. Her daughter lives in the area and is available to assist with activities of daily living, meal preparation, and transportation. I live many states away, but offered to be on site for the first week postdischarge to coordinate home care, lifeline services, transportation, and overnight care. I agreed that we would evaluate her transition and progress after 1 week and consider if any changes needed to be made. As we discussed this plan, the team began to feel more comfortable and encouraged that she could go home, and we saw Dorothy become more engaged and grateful that she was part of the planning process—and heading home, where she wanted to be. I flew to meet my Aunt Dorothy on her day of discharge. We reviewed the transitional plan with the hospital case manager, the physician, and physical therapist.
She was weak and exhausted just getting home, but the smile on her face when she was in “her” chair in “her” home with her cat, Harry, on her lap, spoke volumes. She knew she would need to engage in her therapy plan, commit to exercises that were unfamiliar, and focus on becoming stronger and back to her independent status. Could she do it at the age of 94 years? We believed that she needed the opportunity to try. Home Health Care provided a team that assessed the home for safety, along with PT and OT services and a plan to follow, and encouraged her to set up a lifeline emergency tool in her home. This was all completed, along with an all-important beautician appointment (which she refused to cancel), within the first week of her being home. I knew then, she was on her way back to optimum health and the Aunt Dorothy that I know and love. By the end of the first week she was sleeping at night, on the first floor of her home with a reduction in pain, and increased energy in the morning. She was totally focused on mastering the stairs and getting back to her bedroom on the second floor. Surprising everyone, by the third week at home she was back to her own bedroom, upstairs with Harry. She was back into her routine and no one was happier. Why am I sharing this personal story? As a reminder, all patients are individuals, with their own history, story, goals, and choices. Our role in health care is not easy, no matter what practice setting we are in, or population we are serving. We are pulled in many directions and have many responsibilities; however, I believe that there is no greater responsibility than that of being an advocate. One, that always, no matter how difficult it is, takes time to listen to the individual, takes into consideration their goals and choices, and advocates for them with safe and realistic outcomes. As a postscript, my Aunt Dorothy turned 95 on August 13, 2013. She was at home, going out to dinner to celebrate with family and friends, no walker, no cane, managing independently all levels of her home and outside in her community. She is strong, vibrant, engaged, and choosing her path today, as she has done over the last 95 years. All she needs periodically is a little help from family, friends, and an advocate. As her niece, it is my pleasure and my honor to be that advocate and make sure that she is able to always choose her path. Happy Birthday Aunt Dorothy … and wishing you many more independent birthdays to come!
Mindy Owen, RN, CRRN, CCM, a Charter Board member and Past President of CMSA and Past Chair and Commissioner of CCMC. She is the Principal of Phoenix Healthcare Associates LLC, Coral Springs, Florida, specializing in case management education and management. Her career in health care has included critical care neurosurgery and rehabilitation. She helped design and implement an SCI-TBI rehabilitation department at Wesley Regional Medical Center in Wichita, Kansas. She was the 1st Midwest Regional Director of C.M. for Intracorp and has developed and directed both acute and MCO CM/DM programs nationwide.
Vol. 19/No. 1
Professional Case Management 53
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
PCMv19n1-HeartBeat.indd 53
11/21/13 12:24 AM
