When an elderly person is injured and then discharged from the hospital their needs often extend beyond care one would immediately think of. There are concerns related to their ability to meet all the various requirements for return to previous level of functioning. The patient needs to not only take their medications, make appointments but they may need to change all or some portion of their lives in order to recover and prevent further injury. Involvement of family and other resources is a complicated process that not only involves the patient and their family but numerous other members of the interdisciplinary healthcare team.
In this scenario, a 72 year old male patient, Mr. Trosack, is discharged from the hospital after surgery to replace a fractured hip. He does not participate in regular health screenings and does not take any prescription medications. His wife died two years ago and he continues to live in the same 2nd story apartment he has lived in for 40 years. He has one son who lives nearby but often works long hours. The patient also owns a bakery and would like to continue to own and operate the bakery upon discharge.
Three Healthcare Issues
As the case manager there are many issues with this patient that must be addressed. The top three concerns I have established include: medication regimen, diet, and access to follow up appointments. Each of these concerns are important based on information obtained from patient and family interviews and knowledge about the patient and his past medical history.
Medication regimen may be the hardest and most important. Mr. Trosback self admittedly does not take any medication and arrived at the hospital with undiagnosed hypertension. He also does not like the idea of being “disabled” and his impaired mobility along with his need to take medications he did not have to take before could be met with resistance. His son also reported during the interview that he doesn’t think he needs the medication to control his diabetes. Mr. Trosack needs to have the ability to obtain his medications, which may be impacted because of decreased mobility, know the importance and purpose of his medications, when, how and how many to take and also be familiar with the medication side effects.
Maintaining a healthy diet is an additional concern. Mr. Trosack’s kitchen is clean and well maintained but not large enough to maneuver a walker. He also has additional dietary requirements with his diagnosis of NIDDM. His mobility not only impacts his ability to maneuver in the kitchen but his ability to obtain groceries and carry them up the stairs.
Follow up appointments will be difficult to maintain since the patient self admittedly has not had a physical evaluation in over 10 years. With his history of not getting regular health screenings coupled his attitude about being “disabled” and having to take medications, a regular schedule of appointments and therapy may not be his priority. This may be compounded considering the strain his mobility and 2nd floor apartment would place on his ambulating to a transportation source.
Interdisciplinary Team Members
In order to successfully plan for Mr. Trosback’s discharge from the hospital and eventual return to adaptive functioning, numerous members of an interdisciplinary team need to be able to coordinate care and services. These team members include not only the case manager but also the staff nurse, occupational and physical therapy (PT/OT), mental health professional, social worker and dietician. Each person will have a specific role in Mr. Trosback’s recovery and in order to be most effective and studies have shown that the interdisciplinary team is key to integration of services and successful patient outcomes with the increasing complexity of the healthcare environment (Strasser, Uomoto & Smits, 2008).
In Mauk (2012) the authors review the different members of interdisciplinary team and their roles. The Case Manager is often the team leader in partnership with the physician. He or she fills the role of advocate, liaison and coordinator of care. The staff nurse coordinates day-to-day care and also gives medications and teaches the patient new skills and about their health issues. PT and OT work together with the goal of increasing strength as well as improving the patient’s balance and ability to perform activities of daily living and gross motor skills.
Mental health professionals can include psychiatrists and psychologists who can evaluate the patient’s emotional state and emotional needs, which is related to the patient’s physical recovery as well. A social worker has a similar role to the case manager related to communication of services needed and progress of care but focuses on psychosocial support and helps the patient and family identify and access services needed. The dietician oversees the patients dietary needs and coordinates with other members and the physician to create a meal plan adequate to meet nutritional needs while meeting restrictions that may be set forth by the individuals current medical status.
When considering the long-term outcome of rehabilitation and returning the single approach is not as effective as one that can be provided by a comprehensive interdisciplinary team (Mauk, 2012). Each member is necessary to fill their role in the patient’s rehabilitation and to be active communicators with other team members. Through communication and knowledge of their specialty they can work together to find a location and level of service that meets Mr. Trosback’s needs during his post-operative rehabilitation period.
Each year about half of elderly patients fall and 2% of these falls result in a hip fracture. It is also estimated that half of these patients who recover from a hip fracture still do not return to their same level of mobility (Beers & Berkow, 2005). Mr. Trosback has already suffered a fall and hip fracture and since the overall mortality in 12 months for hip fractures is 18-33% (Beers & Berkow, 2005) prevention of further falls is imperative. The safety assessment identified certain extrinsic factors present in his environment that may contribute to falls (Beers & Berkow, 2005). These factors include the stairs, the apartment being small and cluttered with objects and memorabilia, scatter rugs and stacked carpeting.
Intrinsic factors can include the addition of medications to his current care regimen to control pain and hypertension. These can contribute to unsteady gait, positional hypotension and possible alterations in perception. His history of a fall and the resulting impaired mobility are additional intrinsic factors that increase Mr. Trosback’s risk of falls (Mauk, 2012). The main concern should be maneuvering up to and around his apartment. Two flights of stairs coupled with the small size of the apartment puts him at risk for failing to use his walking aids and experiencing another fall.
Discharge Plan of Care
In order to be safely rehabilitated Mr. Trosback would need to consider spending a short time in a facility better able to coordinate his daily care. He lacks the family resources to provide care and his apartment is not suited for his needs in the immediate postoperative period. He and his family are reluctant to accept the changes associated with his fall and life after surgery. Their failure to accept the fact that his life has changed places him at risk.
Mr. Trosback’s family does not have the resources to personally commit to his care, nor do they understand the extent of his needs. He will need a routine established for medication, changes in diet and exercise. Until he regains his strength he will not be able to ambulate up stairs without assistance and may not be able to ambulate up stairs at all. He will need groceries brought to him and his meals prepared for him while he is dependent on a walker as his ambulation aid. Mr. Trosback’s son and daughter-in-law have a work schedule where they spend greater than 1/3rd of the hours each week working and have historically not visited Mr. Trosback frequently. In addition, the statement that they hope to do better once he is home is indicative of uncertainty about the time they can commit.
Impaired ambulation will decrease Mr. Trosback’s ability to leave his apartment and participate in activities that would have provided him daily interaction with people. This includes shopping, running his bakery and traveling in his neighborhood. If left in his apartment alone he runs the risk of becoming socially isolated, especially if the case is that his son and daughter-in-law are not able to frequently visit him. Research has indicated that social support and social networks reduce morbidity and mortality, especially in older people who frequently suffer from multiple illnesses (Mistry, Rosansky, MsGuire, McDermott & Jarvik, 2001).
In a study of patients at a veterans affairs hospital in Los Angeles, researchers noted that “the group of patients who were socially isolated or at high or moderate risk for isolation, were 4-5 times more likely to be re-hospitalized within the year, than low isolation risk patients” (Mistry et al., 2001). Another study in the United Kingdom showed a statistically significant relationship in level of social isolation and health status (Hawton et al., 2011). Those who were noted to be socially isolated and especially severely socially isolated showed lower scores of health-related quality of life (Hawton et al., 2011).
Psychological Factors – Role in Recovery
Mr. Trosback’s fall was a severe, traumatic and life changing event. In a moment he lost his independence and must face many factors that will stand in the way of his recovery. Mossey et al. stated that patients who suffer from a hip fracture are much more likely to suffer from depression, delaying discharge and resulting in a higher risk of relapse and return (as cited in Proctor et al., 2008). Some contributing psychological factors that hindered recovery included anxiety over future falls, worry over their current situation, phantom pain after surgery, and loss of independence. Each one of these factors can result in a restriction in activity which creates a delay in progress or a relapse (Proctor et al,. 2008).
Suggested Discharge Placement
Initial discharge placement should include the possibility of a short-term stay at a sub-acute inpatient rehabilitation facility. This would allow a period of time for Mr. Trosback to regain his strength, his family to make arrangements to accommodate his new needs and to establish a routine with ambulating, diet and medications. Once he is able to demonstrate independence and the ability to self regulate he should be discharged home.
The goal should continue to be discharge to home because in one study of patient’s after a hip fracture, five-year survival was significantly higher in those who were admitted from home and those who returned to their home at time of discharge (Johansen, Mansor, Beck, Mahoney & Thomas, 2010). Mr. Trosback should also relocate to a location that reduces his use of stairs and eliminate some of the hazards to navigation, such as his memorabilia, excess rugs and cramped cooking areas.
Recovery from an injury that affects mobility is a difficult path, one that becomes more difficult with age and circumstance. In the case of Mr. Trosback, his current living situation and social support put him at a higher risk for recurrent injury. Short term placement in a facility capable of providing for his needs and teaching him to adapt to his new level of mobility after his injury would be ideal until he and his family can develop a plan of care that not only fits their work schedule but his limitations. This is not an easy path for them but with the help of an interdisciplinary team they can use their specialized knowledge and expertise to return Mr. Trosback to a level of recovery.
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