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.

 

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