When the patient plot thickens

Renee Kinder
Renee Kinder

We had a plan. 

We should have known better.

Monday April 3, the eve of the national championship in college basketball. My 10-year-old, Lawson, and I had big plans to watch the 9:20 p.m.-past-bedtime game together.

Dinner at 6 p.m., followed by baths and bedtime for the little ones at 8:00, and Lawson manning the house while I walked the dogs to ensure everyone stayed in bed.

By 9 p.m. we were set, on the couch, ready to enjoy rare mommy and Lawson solo, quality time together.

At 9:15, I message my husband, “Watching the game with bubby.”

Then a major wrench in the tiniest of forms enters the picture via 2-year-old Emmy Grace with a miniature shopping cart full of toys. She announces as she enters the den with great joy in her voice, “I am here!”

Our plot thickened.

The next set of texts to my husband at 9:30 were as follows.

“Emmy is out on the deck in the rain with Macy” [our golden retriever]

“And she is singing loudly ‘The Wheels on the Bus'”

“With an oversized Easter egg on her head”

I liken my experience to the level of ever-adjusting care that providers in skilled nursing facilities face daily.

Providers must not only plan to provide care to the new stroke patient or the new hip fracture patient, but they must provide exceptional care to that new patient for their primary diagnosis, on top of multiple complexities and co-morbidities, possibly including COPD, various forms of dementia, and infections such as UTIs, which are so prominent in the geriatric population.

Take, for example, the first patient I treated as a speech language pathologist in long-term care.

The referral read, “Dysphagia secondary to CVA.”

Dysphagia due to a stroke. I've got this all day long. Or so I thought.

I start with review of the medical record. For some reason, I cannot locate the specific MRI or CAT scan that provides me with information on localization of the stroke. Hmmm. Guess I will keep looking. Then I see the “complexities” section which includes: CHF, COPD and dementia.

My plot thickened.

I know how to treat the right or left CVA. How do I treat the CVA with these complexities?

Providers in skilled nursing facilities can and do, day after day. Additionally, the medical complexities that SNF teams are tasked with treating are often directly linked to risk for rehospitalization.

On March 7, the Centers for Medicare & Medicaid Services announced that its Initiative to reduce avoidable hospitalizations run through the CMS Innovation Center has lead to potentially avoidable hospitalizations for beneficiaries in nursing homes in addition to leading to quality improvements in seven areas.

Focus conditions included: pneumonia, congestive heart failure, urinary tract infections (UTI), COPD/asthma and dehydration.

Take, for example, an individual admitted to a skilled nursing facility following hip surgery with no comorbidities. This person will demonstrate a simplistic plot in comparison to the individual following hip surgery with baseline dementia and history of recurrent UTI, which results in confusion, which results in unsafe acts, which results in risks for pre-mature weight bearing status.

Care providers can combat these complex plots by pro-actively establishing interdisciplinary care pathways to monitor these conditions.

Doing so can help the SNFs provide care to patients even when their plot thickens without the result of the unnecessary climax of a readmission to the acute-care setting.

As for my battle to calm a 2-year-old eager to enjoy a late night, I allowed the rising and falling action to unfold before me, ending with a resolution that all parents must face with great sadness.

Moving forward my pro-active approach is that it's time for this toddler to nix the midday naps.

Renee Kinder, MS, CCC-SLP, RAC-CT currently serves as Director of Clinical Education for Encore Rehabilitation (insert: www.encorerehabilitation.com)  and acts as Gerontology Professional Development Manager for the American Speech Language Hearing Association.

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Rehab Realities is written by Renee Kinder, MS, CCC-SLP, RAC-CT.  She currently serves as Director of Clinical Education for Encore Rehabilitation and acts as editor of Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.

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