Long term care scenario

Su is a 78 year old widow who had a severe stroke.  She was taken to the ER and admitted to acute care.  She is transferred using a mechanical lift, has expressive aphasia, is not able to swallow and is fed through a PEG tube.

She has a supportive family but her daughter lives in Manitoba with her husband and 3 young children, one son is single and lives 3 hours away and another son lives in the same city as Su with his wife and 2 young children. 

Su, her family and the health care team have decided that she will be transferred to a long term care (LTC) facility.

What information should be included in the discharge summary?

Learner lists ideal summary - compares to exemplar - Learner adds omissions, corrections.

What preparation should be done at the long term care facility?

Staff education, assessments

What education for staff should be provided?

What referrals should be made at the LTC facility?

Who should be involved in care planning for Su?

After 4 weeks working with a Physiotherapist and Dietician, Su has made significant progress and is now able to transfer with the assistance of 2 care workers.  She is beginning to swallow and is trying a modified diet.  A family meeting has been arranged to discuss her progress.

How can staff monitor and assess education needs?

What education would be appropriate at this time?

How can Su and her family help the team?

Scenario 4 Albert, a 56 year old stroke survivor with right sided deficits and a mild expressive aphasia, has just completed rehab in a tertiary rehab centre. He has recovered to the point where he can transfer with a 1 person assist. He is cognitively intact and has expressed the desire to return home to live with his 46 year old wife and 9 year old son. In the interim, he will have to return to the Healthcare Centre in his home community. What communication options are available to support Albert’s transition back to his community Healthcare Centre? a. Use of Telehealth to link rehab team from Tertiary Centre and local HCC Healthcare Providers b. Transfer sheets with completed discharge functional assessments c. Telephone/ Teleconference discussions d. All of the above How can the local HC Team support Albert’s transition to home? a. Meet with wife to determine her ability/ desire to meet his care needs b. Assess potential for other care providers c. Do a home assessment to determine wheelchair accessibility d. Provide training to caregivers e. This could be a “what’s missing” question??? Albert has been home for 3 weeks now. His wife had taken vacation time off from work to care for him, but now must go back. Albert can spend some time alone, but does need some assistance for meal preparation and toileting. He is also becoming quite bored and restless spending most of his time in the house. What could be done to support Albert and his wife at this stage? (consider respite care, alternate caregivers, support from Alberta brain injury network, DATS transportation, access to community sports arenas) Albert has been more active the past couple of weeks as he got back out into the community. A previous smoker, he’s experienced increased cravings as he’s joined his friends again for coffee, and at one point, he smoked a cigarette. He has also been having increasing weakness in his right leg in the evenings and was also expecting to have more function in his right arm by this point. Albert is feeling discouraged and blames stress for his higher than normal blood pressure readings. What options are appropriate for Albert at this stage? a. See his PCN physician and team b. Participate in a self-management group c. Review education material regarding stroke recovery d. Contact rehab department Albert has made an appointment to see his PCN physician for follow up. What support can the PCN team provide for Albert? a. Complete Stroke Checklist to determine how well Albert and his family are coping b. Advise Albert about post-stroke fatigue as it relates to his evening symptoms c. Compete depression screen and refer as necessary d. Provide education regarding realistic expectations at this stage of recovery e. Provide education regarding risk factor management to prevent another stroke f. Support Albert in setting some patient centred goals for moving forward g. Make referrals to chronic disease management education programs h. Review Albert’s medications and compliance i. Refer to a smoking cessation program/ support group

Scenario 4 Albert, a 56 year old stroke survivor with right sided deficits and a mild expressive aphasia, has just completed rehab in a tertiary rehab centre. He has recovered to the point where he can transfer with a 1 person assist. He is cognitively intact and has expressed the desire to return home to live with his 46 year old wife and 9 year old son. In the interim, he will have to return to the Healthcare Centre in his home community. What communication options are available to support Albert’s transition back to his community Healthcare Centre? a. Use of Telehealth to link rehab team from Tertiary Centre and local HCC Healthcare Providers b. Transfer sheets with completed discharge functional assessments c. Telephone/ Teleconference discussions d. All of the above How can the local HC Team support Albert’s transition to home? a. Meet with wife to determine her ability/ desire to meet his care needs b. Assess potential for other care providers c. Do a home assessment to determine wheelchair accessibility d. Provide training to caregivers e. This could be a “what’s missing” question??? Albert has been home for 3 weeks now. His wife had taken vacation time off from work to care for him, but now must go back. Albert can spend some time alone, but does need some assistance for meal preparation and toileting. He is also becoming quite bored and restless spending most of his time in the house. What could be done to support Albert and his wife at this stage? (consider respite care, alternate caregivers, support from Alberta brain injury network, DATS transportation, access to community sports arenas) Albert has been more active the past couple of weeks as he got back out into the community. He noticed some increasing pain and stiffness in his right leg. He also was expecting to have more function in his right arm by this point and is getting discouraged by the progress. What referrals could assist Albert at this stage? a. See his PCN physician and team b. Depression screening c. Stroke checklist

Table Patient Education Across the Curriculum

Shirley's Transition Checklist (Updated)

Link to doc

Checklist of Discharge Summary or Transfer Summary OR Transitions Summary Checklist

From: Transitions Module Master Internal Review 1 Oct 2015

LTC scenario

Long term care scenario

 

Su is a 78 year old widow who had a severe left MCA stroke.  She was taken to the ER, admitted to acute care and then transferred to an inpatient stroke rehabilitation facility.  She has a supportive family but her daughter  lives in Manitoba with her husband and 3 young children, one son is single and  lives 3 hours away and another son  lives in the same city as Su with his wife and 2 young children.

After 8 weeks in rehab, she is still not able to live on her own, so she is being admitted to a long term care facility next week.

What information should be included in the discharge summary?

What preparation should be done at the long term care facility?

Su made significant progress towards her rehab goals but is still unable to walk independently and ongoing speech and swallowing problems meant that she is on a modified diet.

What should the facility offer Su?

Who should be involved in care planning for Su?

 

 

 

 

Comorbidities include diabetes, knee replacement 5 years ago, atrial fibrillation, hypertension.

 

Hi

Revised Case Study 2: 28 year old repeat admission

CASE STUDY: On 9/17/2013; 28 y/o female Syliva admitted through the ED for right sided numbness; headache, double vision and mild expressive aphasia. ( works at Tim Hortons) Symptoms had started 16 hours ago while at a party. No past medical history; no past medications.

• Person who brought her in says she lives alone
• Indicated not wanting to be admitted
• She does not drive

Transition Plan:
Will be transferred and admitted to stroke unit.

( we will multiple choice the questions below)

• What patient education would be best suited at this transition point?
• How do we know what the patient is ready for?
• How do we determine what the patient educational needs or desire to know is at this point?

After healthcare professional educates patient on the value of being admitted to stroke unit, patient agrees and enters stroke unit.

• What would successful patient information  between departments look like in this situation?

Patient arrived too late for acute stroke intervention, will be transferred to stroke unit.                     

Patient concerns: - what happened? It will be difficult for a 28 year old to accept they had a stroke. Patient needs:    

·         Teaching on mechanism of stroke and recovery

·         Signs and symptoms of stroke

·         Supporting return-to-work concerns

Healthcare team focus:

·         Transfer to stroke unit for rehabilitation

Hospital course: Admitted to stroke unit; consult with Neurology; NIHSS upon admission was 2; CT Head was negative for acute process, MRI of brain showed acute left pontine infarct. MRA was negative with patent carotid and vertebral arteries. Hypercoagulable workup was negative. 2D echo was negative and TEE completed.

                Stroke Team focus:

·         Complete diagnostic testing and determine stroke etiology

·         Provide appropriate treatment for patient

·         Start Rehab

·         Discharge planning

Patient’s concerns:

·         When will I get better?

·         Patient will need teaching on stroke recovery, timelines, activities to promote…

·         Describe the roles of the different therapists and other team member; inform patient of community services available to assist her once she is discharged

·         Will I be able to work?

·         Referral to Glenrose or other out-patient stroke assessment services for neuropsychology testing and Return-to-Work assessment

·         Contact employer for a discussion on modified RTW duties

·         Will I be able to function at home on my own?

·         Propose a home assessment

·         Refer to Homecare

·         Assist patient to write a list of support people to contact

·         Refer to out-patient therapy programs

·         Can I still drive?

·         Refer to Drive-Able or other driver assessment programs

·         Help patient plan alternative transportation modes

·         Discuss the impact on insurance, etc. if patient drives with a disability and is involved in an accident              

Disposition: Patient discharge home on day 5, ambulating with a mild gait disturbance; and mild dysarthria. Acute rehabilitation was recommended but patient refused. Stroke instructions were provided. Follow up appointment was made with primary care physician; TEE results were pending. Medications: Aspirin. Discharge summary suggested follow up with Cardiology for loop recorder.

                Stroke Team:

·         Provide discharge teaching – S&S of stroke, medications, importance of follow-up

·         Ensure follow-up appointments and appropriate referrals are made, and patient has contact information for each location:

·         Stroke Prevention Clinic

·         Driving assessment/RTW assessment

·         Homecare

·         Cardiology follow-up

·         Family physician

·         Arrange home assessment to determine whether patient would benefit from equipment and ADL aids.

Patient concerns:

·         When can I drive?

·         Ensure patient has contact information for driver assessment

·         When can I return to work?

·         Ensure referral is sent and patient has contact information

·         Who can I call if I have problems or concerns?

·         Stroke Navigator/Stroke Lead; Stroke Program Edmonton Zone

Patient was readmitted on 10/31/2013 for new left sided numbness, and a chronic headache x 1 month. She had stopped taking her ASA – she states ran out. Cardiac monitor showed one episode of atrial fibrillation. MRI this admission now shows tiny multiple right subacute infarcts in the left and right internal capsule. POOR TRANSITIONAL CARE: Her failed follow up; No support at home; poor understanding of condition and social situation. TEE results had no follow up; Discharge recommendations for Loop recorder were not completed. Follow up with Cardiology was not completed.

Despite our best efforts, this patient was readmitted for the same problem. What Factors Contributing to Readmission?

·         Poor health literacy

·         Poor understanding of diagnosis

·         Inability to identify signs of stroke

·         Non-compliance or poor management of personal risk factors

·         Non-compliance with Medication regime

·         No Follow- up care

·         Confusion: due to TOO MANY TRANSITIONS with multiple health care providers

What other ways can we support this patient to improve outcomes and reduce risk of recurrent events?

·         Post-stroke support group e.g. Stroke Recovery Association

·         CDM courses on risk factor management

·         Stroke learning activities e.g. Living with Stroke

From the Library

3 main areas areas for focus questions

Trudy and I were discussing the questions' focus. I summarized where we got to here.

Patient & Family

What does the patient need to know specifically at this time?
Remember patients may have other challenges
What HC members can you access to assist you at this time?

Healthcare Teams

Education to patient, assessing what they are ready for ( depression, receptiveness, anxiety, level of self help) , barriers to follow up, how to involve patient

Transitions Perspective 

Help patients take responsibility.  Continuity of patient information from HC professional to healthcare professional. Discharge plan. Continuity of care: supportive of communicating  discharge plan to the next transition point.
What tools can we put in place to support Continuity of Care ( Discharge plan)?

Highlights of the moderate and significant updates as well as new additions to Managing Stroke Transitions of Care module recommendations for 2015 include:

•   A focus on patient-centred care, with the patient, family members and caregivers included as active members of the stroke team, being involved in decision-making, goal setting and care planning throughout the stroke care continuum;
  
•   Recognition that stroke affects the whole family unit, and places a burden on family members; ensuring caregiver capacity, coping, and risk for depression are assessed and monitored;
  
•   The importance of educating patients and families to understand the nature and cause of stroke, the signs and symptoms, the impact and the ongoing needs of the patient who has experienced a stroke;
  
•   A call to action for all healthcare professionals for delivering education and support on an ongoing basis, regardless of patient location within the healthcare system, including providing new information at the right teachable time, reinforcing previously taught information, and assessing ongoing learning needs; these information needs evolve as the patient moves through the continuum of care and into longer term recovery;
  
•   Promotion of self-management and active participation in ongoing care, adhering to rehabilitation plans and actively engaging in recovery, and following through with decisions to take prescribed medications;
  
•   An emphasis on improving communication: between healthcare professionals and the patient, family and caregivers; and between healthcare professionals, particularly when patients are transitioning between care settings or discharged home. 
  

Case Scenario- rural

Andy, a 63 year truck driver, was just returning to the worksite after a delivery in the country.  As he approached the traffic lights leading into town, he suddenly felt dizzy and then lost his vision.  Although in a panic, he was able to radio for help and a co-worker brought him to the local Healthcare Centre.  On arrival at the HCC, his vision was improving, so the ER physician did not feel admission was warranted.  Arrangements were made for the patient to be seen as an outpatient at a tertiary Stroke Prevention Clinic the following day. 

When the patient realizes he is improving and will not be admitted, what questions/ concerns might he have?

(What caused the event?  What tests will I need?  Is it going to happen again?  Can I go back to work? )

As a HC Provider in ED, what support/ assistance can you provide to the patient/ family during this transition?

(Confirming and validating patient’s fears, concerns and questions.  Providing information regarding cause of stroke/TIA, http://www.heartandstroke.ab.ca/
outlining the plan of care at this point, confirming patient has transportation to get to appointment in tertiary SPC, ensuring patient knows location of SPC, advising patient if symptoms get worse to call 911)

As a HC Provider in ED, what inter-departmental/ inter-facility communication needs to occur to ensure continuity in this patient’s care, and what tools could be used to support that?

(telestroke consult with stroke neurologist, completing all aspects of the SPC referral form to ensure adequate information is provided, faxing referral to the right location and attaching supporting documents as necessary for a complete history of event and investigations completed while in ER.  Clarifying whose responsibility it is to ensure documents are faxed)

Andy was seen at the SPC where he had a head CT and CTA and was found to have had a small ischemic stroke.  A repeat visual exam at the SPC confirmed a persistent loss of peripheral vision and a mild balance problem.   Andy was advised not to drive due to the visual deficits, and could therefore not return to work.   He was given a prescription for Aspirin 81 mg and Crestor 10 mg daily and was advised to buy a BP monitor and check his BP daily.   He was also advised that he would be scheduled for a Holter Monitor test and should have some rehab therapy to assist with recovery.

What would be the patient/ family concerns during this transition?

(Will my vision ever return?  How do I tell my boss?  Will I lose my license?  Living in the country, how will I get around?  Worried about losing independence, what will be the financial impact of not returning to work?  How will this affect my wife and family? Why am I on these medications?  Will I have to take them forever? What is a Holter monitor?)

As a HC Provider, how could you support Andy and his wife during this transition?

(Provide info regarding driving after stroke and outline Andy’s responsibility in notifying the MVB.  Provide information or who to contact regarding alternate transportation options in the community, Provide letter for employer as requested, offer referral to Social Worker regarding financial concerns.  Outline realistic expectations for recovery.  Provide information regarding medications and testing.  Assure patient that you will communicate his plan of care to appropriate team members.  Advise Andy to make an appointment with his family Dr within a week or two to ensure on-going follow-up)

As a HC Provider, what inter-departmental/ inter-facility communication needs to occur to ensure continuity in patient care?

(Referral to rehab needs to be completed and faxed in a timely way.  Advise Andy that he can be pro-active and contact the rehab department to confirm referral.  SPC needs to have access to community rehab list to ensure therapists are available in that community.  May need to phone and confirm that therapist is trained in visual rehab therapy.  Letter to family physician needs to be forwarded in a timely manner.  CT/ CTA and bloodwork results will be available on Netcare.  Requisiton for Holter Monitor needs to note that results are to be sent to the family doctor as well as the stroke neurologist)

Andy was seen by his family physician within 1 week of the SPC consult.  His doctor reviewed recent fasting bloodwork and his blood pressure readings since the SPC clinic visit.  Andy was known to have mild hypertension for a number of years, but was reluctant to take medications.  Most of the recorded BP readings this week were greater than 155 systolic and greater than 100 diastolic.  Andy was advised that he needed to be on anti-hypertensives  to control this risk for stroke.  As well, his fasting lipids were elevated.  His Holter monitor results were not available at this appointment.  Andy told his physician that he had an appointment with the OT at the Healthcare Centre that same afternoon.

What would be the patient/ family concerns at this time?

(Andy needs to know more about managing risks for stroke, need to feel supported by PCN staff and able to provide input in care decisions and goals for reducing risk)

As a HC Provider,(PCN physician or nurse) how could you support Andy and his wife at this time? 

As a PCN nurse or physician, what interdepartmental/ inter-facility communication needs to occur to ensure continuity in patient care?

Focusing on Questions

Questions and Transitions

The conversation today was on developing questions and where they might be appropriately asked.

A transitioning example:

From the Healthcare Professionals' future care perspective:
A stroke patient transitioning from Emer discharge with HC potentially will have a number of different future care options to be decided. 

From the Healthcare Professionals' informing ( teaching ) patient of the diagnosis perspective:
At the same time Patient and families need to learn what has happened medically and what their next steps are going forward.

Colleen offered to take some time to rewrite questions with the above in mind.

See you all Monday.

This is proof of concept that I can actually do this!

Check list on writing a case scenario

Present the Situation: 

Do not give any signals that one solution might be preferred.

Provide Relevant Details: 

provide  relevant details about goals, strategies, dilemmas, issues, conflicts, roadblocks, appropriate research, relevant financial information, people, and relationships.

Use Dialogues: 

Make the characters come alive with dialogue. Straight narrative is boring.

Challenge: 

Leave the reader with a clear picture of the major problems--either ask or imply what is to be done now?

Case Studies vs Learning Objectives: The Table

Making the case . . . comparing our learning objectives to our cases.





Links to case studies:

28 y/o female admitted through the ED for right sided numbness

Andy, Rural 63 year old truck driver

Comparing Case study Branching Learning Approaches

We are planning a case study here.

Key Components of Transition

These key components of transition, taken from page 4 of the best practice document, encapsulate for me the direction I would like to see the module take and the scope of coverage:

All members of the healthcare team for stroke patients and families are responsible for taking action to ensure successful transitions and facilitate a successful return to the community following stroke.

Key components of successful transitions include:

 collaborative goal setting between the healthcare team, patients and families, where patients and family members actively participate in discussions and planning with the healthcare team and are involved in shared decision-making;

 ongoing education for patients, families and informal caregivers that reinforces key information and verifies understanding;

 patient, family and informal caregiver education needs to occur for all stroke patients, regardless of setting; this includes in the emergency department, primary care, acute inpatient care (regardless of location of patient within the hospital), rehabilitation settings, outpatient and community settings;

 skills training appropriate to needs and goals of patients to facilitate safe transitions;

 discharge planning that begins soon after stroke admission and all relevant support services, such as home assessments and access to ambulatory and community-based rehabilitation;

 assessment of family and informal caregiver capacity to provide ongoing care for the patient with stroke, as well as their individual support needs and potential burden of care;

 timely transfer of medical information between stages of care to ensure smooth transitions in care;

 identification of and linkages to community resources, long term care and home-based care;

 ongoing surveillance of physical, psychological, social and emotional recovery, coping and adaptation following discharge from inpatient acute care and rehabilitation settings.

Begin at the Beginning . . .

Trudy, Colleen and myself began the process.

Take aways:

• Tentatively we meet 9 am Monday & Friday  ( 1/2 an hour)
• Meeting with:  tele-conference and blog site and google docs - this actually showed promise - All were able to see the blog site and the google doc, so this may be the venue we keep.
• until better alternatives come about . . . 
• Shirley returns next week.
• Next week finish up Scope doc
• Colleen and Trudy will pull ( begin to)  major take aways from National Stroke Transitions doc ( see link below). 

Managing Stroke Transitions of Care - Best Practices

Welcome

Welcome Colleen, Trudy and Shirley,


I am hoping that we might use 'blogger' ( this interface ) to build the Transitioning Stroke Patients Course.

I hope this will provide a place for:

1.  Discussion
2. Tracking Progress
3. Place for others to comment on beta versions
4. Request changes
5. Store knowledge
6. Store files

In other project builds we have used SharePoint and email but I feel this will allow us a friendlier more inviting place to share and work together. I am here to support all of you in this endeavor and am happy to answer any questions about using this tool.

In the mean time I would hope you might consider putting documents up to this site so that we may begin to assemble the knowledge that we might need to move forwards.


I wish you a warm welcome and if you have any concerns, please reach out so I can assist you.

Mark Sheridan

To begin I would like you to try and post a comment in the comments below.

If you are feeling adventurous we may try to add a  post, a document or image.

Scoping Doc Template

Link to Scoping Doc

Pre Scope Doc Meeting Notes

Notes for  the Scoping document

basic knowledge about how to transition in healthcare - what needs to be in place to transition stroke patients through different stage of their recovery; what resources are important for patients in the community; transition from acute to community care/primary care

Colleen plus others on a working group for the project; zone SME, frontline staff to sit on the working group (Colleen to identify); no hard timeline for the project.

zonal specific resources - Edmonton specific; access resources (people and documents) by zone;

Discharge document didn’t get much uptake from clinicians.

NetCare - PC have access

Provider to THINK through a process rather than a strict step-by-step process

Tech Links that Support This Process

Six great ways to use blogs for project management

Collaborative Blogging --How To . . .