Mr. Trosack is a 72 year old man who fell down a long flight of stairs a month ago, underwent a total hip replacement and is in need of a discharge plan. He completed two weeks of rehabilitation in the hospital for his hip as well as diabetic teaching for his new onset of Diabetes. It was also discovered during this hospitalization that he needed to start taking medication for hypertension. Both he and his family are in denial about what it will take to get him home and deliver the care that is needed.
Healthcare Issues and their Importance
Discharge planning and management with an elderly person can become very complicated and should be approached with an open mind and the willingness to compromise with the family and patient himself, keeping in mind that the safety of the patient is top priority. Before Mr. Trosack can safely be discharged home several issues have to be considered. It is important that the case manager meet with the patient, his family as well as find out about the details of where he will be going and how much assistance from family and friends is available and dependable. One of the issues that needs attention is his physical preparation to move back home. In his current state, he is not able to take care of himself without help. Based on the interview of his son and daughter in law, as well as taking into consideration their lack of help prior to the surgery, it doesn’t appear that they will be able to visit him often or consistently. That will not work immediately because Mr. Trosack will need daily assistance, for several more weeks. A rehabilitation center may be his best option in order to ensure his safety and avoid another fall.
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He will be able to continue physical therapy sessions in order to continue to improve as well as round the clock help when needed. He would receive more stair climbing training, hip strengthening exercises as well as gait training. Attending the rehab program would also allow him to socialize with people facing similar obstacles and adjusting to a new way of living. An Occupational Therapist (OT) can be consulted to assist with adjusting to his activities of daily living. Continued monitoring of his new medications as well as extra help with blood sugar monitoring may help him deal with the denial of his new onset of Diabetes and Hypertension. The specialists at the rehab center will be able to assess and determine when Mr. Trosack is ready to go home and can be independent with minimal assistance. Preparing him properly the first time can avoid other accidents as well as motivate him to keep working on his strength and endurance.
Another important issue to consider before discharge planning is the safety of his home. Assessing and making changes to his living conditions is a must. After the safety assessment was completed it was obvious that changes had to be made at home to accommodate a person with new disabilities. Since the apartment is cluttered, it must be cleaned up. There are several “memorable” treasures that he has at home; presently they are hazards because of their location. They do not have to be thrown out but they do have to be moved. The kitchen, bathroom, living room, entry way and one bedroom all need to be free of throw rugs, collectables and furniture that blocks the passage of a walker.
There are two rooms in his apartment so one should become a storage area for all of the clutter until Mr. Trosack has moved beyond a walker or cane. The bathroom needs to have permanent safety rails installed near the toilet and bathtub or shower as well as a non-skid applied to the bathtub surface. The medicine cabinet should be cleaned out and all expired or unnecessary medications discarded or returned to a pharmacy. The kitchen is in good order but the refrigerator needs to be cleaned and the expired food thrown out. The living area needs to have minimal furniture and placed so things are easily accessible and not in the flow of traffic. Night lights or motion sensors need to be added to avoid a fall when he gets up at night to use the bathroom. Addressing the stairs is not a simple solution.
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As long as Mr. Trosack is able to walk those stairs following a discharge from the rehab then he can move back home. Side rails on both sides need to be secure and easily accessible to him at a safe level for him to hold on to. Some apartment complexes have added elevators or elevator chairs, if that is an option then that would be fantastic. These issues need to be addresses to avoid another injury at home such as a fall. Mr. Trosacks new diagnosis of Diabetes and Hypertension need to be addressed. There are many psychosocial issues with his new disabilities and diagnosis. These are important because he needs to be able to accept his disabilities and take care of his health, in order to avoid serious complications, heal and cope. It is clear that Mr. Trosack is having a difficult time accepting his new medical diagnosis as well as not being able to be independent.
His comments about being able to handle it all himself at home but yet communicating his frustrations by having to take medications and not being able to get up and down the stairs speak volumes. Continued diabetic teaching may help him understand the importance of food choices and listening to his body’s signals of low or high blood sugar levels. Even after discharge from the rehab center Mr. Trosack should continue having a home health nurse in for periodic visits since it may be difficult to get to doctors’ visits to check blood pressure and blood glucose. A portable glucose monitor and automatic blood pressure should be purchased and kept at home. The mental preparation and coping mechanisms will need to be addressed prior to leaving the rehabilitation center. Denial from the patient and family tells the health health care And Team Members">care team that teaching needs to be done in all areas and with all heath care team members.
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Team Members and their Roles
Discharge planning for an elderly patient requires a team of health care professionals as well as family members working together in order to have a successful transition to home. The case manager needs to be in charge of organizing the team and following Mr. Trosacks progress in order to direct the team based on his changing needs. A Physical Therapist has been working with Mr. Trosack in rehab and that work needs to continue. He needs to improve stair climbing and increase his strength. He will need to work on a generalize exercise program as well as specific gait, balance and coordination to help him become independent at home.He will need to learn to use a walker and cane. Research supports the most effective interventions to manage falls risk are those that incorporate exercise and that exercise program needs to be structured, progressed, and must achieve the minimum dose of exercise (Shubert, 2011).
An Occupational Therapist (OT) should be involved with evaluating Mr. Trosack and making sure he and his house is ready for his return.
Occupational therapy services include comprehensive evaluations of the home and other environments and recommendations on equipment and training as well as guidance and education for family members. They try to adapt the environment to fit the person. (“AOTA,” 2012).
Mr. Trosacks son or brother should work with the OT to coordinate the bathroom safety bars and no skid flooring as well as making sure all excess furniture and collectables are placed in the second bedroom. A dietician should educate him on how to prepare diabetic and heart healthy meals. Diabetic teaching is so important for patients living alone. If he does not take his diabetic diet seriously he may end up with inconsistent blood sugars which in turn can lead to unstable mental status and generalized motor weakness.
A Social Worker will be able to assist Mr. Trosack and family with financial and social needs. The Social Worker can assist with completing paperwork for financial assistance and medical equipment needs. Mr. Trosack may be able to get financial assistance for medical equipment such as safety bars for his house, stair lifts, and exercise equipment. The social worker can also assist in getting him meal delivery and get the patient involved in some social activities. Coordinating family visits and family assistance should be done with the Social Worker and should be coordinated based on lack of outside assistance.
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Social workers are challenged to enable patients and families to have control over decision making regarding their discharge planning(Kadushin & Kulys, 1993).They are trained to help patients and families help themselves. The social worker can help the family identify resources such as home health aids to come to the house when family cannot. Social Workers are also trained in counseling and may be able to help the patient and family cope with the transition. A Home Health Agency could send in a Registered Nurse (RN), Licensed Practical Nurse (LPN) or a Certified Nurses Assistant (CAN) to monitor blood sugars, monitor blood pressure, monitor medications and continue teaching on all of those as well as assist in his Activities of Daily Living (ADL).
This team needs to work with Mr. Trosack’s physician who oversees the plan of care, helps determine services and assists if consults or reports needed for insurance reasons.
Safety
Safety one of the main concerns when discharging a patient. The case manager needs to know that the patient is ready and equipped to make a smooth transition so he will not be readmitted to the hospital shortly after discharge. As discussed in the assessment, Mr. Trosack cannot be discharged home because of several safety concerns. He is not strong enough to climb the stairs, his home is not ready to receive him in its current state, he and his family are in denial of his needs, and the team has not been established to assist him, so it is not safe to send him home. If he is able to continue Physical Therapy he should gain enough strength to climb up and down once he arrives home.
In his home, many areas need to be cleaned of clutter so he doesn’t trip or fall. He will most likely be using an assistive device such as a walker or cane and they can easily become caught up in rugs or furniture. A clear path around the apartment in required and gait training will be part of his therapy. Taking into consideration all the safety issues that will determine another fall or even more serious complications it should be strongly suggested by the case worker that Mr. Trosack continue in an inpatient rehabilitation facility in order to give him time to improve his strength, health and coping mechanisms. This will also give him and his family time to process his needs when he comes home as well as get the home and services needed.
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Discharge Plan Needs
Family is a necessary part of discharge planning. In this case, Mr. Trosacks only family member isnot able to assist him adequately to meet his needs and avoid an injury or readmission. His son and family are too busy and his brother is elderly. Depending on this family for necessary daily needs is not realistic. Along with not being prepared physically, they appear to be in the same mind frame as Mr. Trosack regarding the denial of new medical diagnosis as well as his physical restrictions. Teaching needs to become a priority and the team may be able to help with realistic goals for the family. This is where the social worker and home health nurse could be of most assistance.
Mr. Trosack will need to have some sort of “meals on wheels” delivery of food when he returns home. It may be temporary but should start out that way to avoid missing meals. After he is comfortable and capable of preparing his own food he may opt to have the grocery store deliver a few times a week. Also grocery delivery should be requested. The family can help do some of the legwork for his arrival home. They need to be educated on what are needs and wants for a patient coming home from a hip replacement so that they know what they need to do and what they need to outsource to private agencies. Educating them will hopefully allow them to see that Mr. Trosacks is in need of help even though he denies it.
Social Isolation
Our mental and physical states of health depend on each other. After any life altering surgery older adults end up socializing much less if their activities of daily living are affected. In Mr. Trosacks case, he will need to stay in physical rehabilitation longer and will not be as independent as before the fall. A limited physical mobility usually means limited social interaction. Limited social interaction can decrease his motivation to continue exercising and strengthening his body and could lead further to depression. Familiarity and stability are essential in order for him to be able to cope and heal (Nichols & Riemer, 2008).His social interaction with his family may be strained because they are focused on helping take care of his physical needs and not focused on laughing, having fun and enjoying time together.
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Psychological Factors
A human’s thoughts, feelings and attitudes all influence their behaviors; those behaviors then begin to determine how they will handle stress. Having a hip replacement is frustrating and stressful for patients and families not only because of the physical changes but psychological. Mr. Trosack is used to caring for himself and is now not going to be able to do that. The sudden lifestyle change is an added stressor that he needs help to cope with. “If stress becomes persistent and low-level, all parts of the body’s stress apparatus (the brain, heart, lungs, blood vessels, and muscles) become chronically over-activated or under-activated. Such chronic stress may produce physical or psychological damage over time” (University of Maryland, 2009).
Mr. Trosack should be encouraged to get some cognitive behavioral therapy either one on one or support groups once he is moving around more easily. It will be important for the health care team once Mr. Trosack goes home, to motivate him to keep up with exercises, proper diet, relaxation techniques, and continually monitor stressors involved. Mr. Trosack has already shown signs on denial with his new medical problems. He is not happy to have to take medications and if he does not get help to understand and accept his new medical conditions he will run into an even further disabling state. He has lived in his home for many years so it is best to do everything possible to make that happen.
Recommendation
As stated earlier, the inpatient rehabilitation center is the recommended place from Mr. Trosack to go to before heading home. He needs the extra attention and encouragement in order to be able to take care of himself. He is not strong enough to move back to his house nor is his house ready to receive him. His family support is will not be consistent, soother arrangements need to be made for meals and transportation as well as activities of daily living. He may not accept the idea of more rehab because he really wants to get home but hopefully after teaching him the importance of doing things rights the first time to avoid another fall, he may agree. He also needs to be assured that the teams goal is to get him home as quickly as possible, so the harder he works the faster he may get home and become more independent. The team needs to try to avoid having him move from the place he has lived in and loves.
Reference
Shubert, T. (2011).
Evidence based exercise prescription for balance and falls prevention. Journal of Geriatric Physical Therapy, 34(3), 100-108. The American Occupation Therapy Association (AOTA).
(2012).
Retrieved from http://www.aota.org/consumers.aspx Kadushin, G. & Kulys, R. (1993, November).
Discharge planning revisited: what do social workers actually do in discharge planning?. Social Work, 38, 713-726. Nichols, T., & Riemer, M. (2008, June).
Post surery social isolation. Presentation deivered at 17th world concil of enterostomal therapists (wcet) congress , Ljubljana, Slovenia. Retrieved from http://www.hollister.com/us/files/pdfs/ce09/psychosocial/910298.pdf University of Maryland. (2009, February 13).
Stress. Retrieved from http://www.umm.edu/patiented/articles/stress_000031.htm
