HSE 210 Final Collaborative Care Guide
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Final Project – Collaborative Care Guide
Molly Strempfer
Southern New Hampshire University
HSE-210 X1247 Healthcare Systems
Dr. Lena Klumper
October 15, 2023
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Jean is an 87-year-old female patient who was admitted to Manchester Community Hospital in Manchester, NH due to a right hemispherical ischemic stroke which has caused Jean to suffer from left sided hemiparesis. During assessments performed by Jean’s medical team, it was determined that due to limited mobility, Jean required assistance with eating, transferring to and from her wheelchair, as well as most other activities of daily living. In addition to the physical challenges that Jean faces during the recovery process, she has an existing diagnosis of post-traumatic stress disorder due to experiencing sexual assault at the hands of her neighbor several years ago. Furthermore, after a stroke, many survivors experience emotional and behavioral changes. It is possible that the patient’s stroke could exacerbate symptoms of her existing PTSD.
Luckily, Jean does have social support from the community where she resides, the Catholic Church, and several clubs she belongs to. It has been noted that Jean derives significant comfort through her faith. It has also been reported that Jean has a wonderful sense of humor, was an elementary school teacher, and is a highly organized person. Although her grown children do not live nearby, they are currently staying in Manchester and have indicated that if it is deemed essential by the medial team, they will be able to assist Jean after discharge from the hospital. Prior to admittance, Jean relied on social security and her pension to support herself. Unfortunately, her hospitalization has led to a depleted savings account and there are concerns about mounting medical bills due to inadequate medical insurance as well as the costs of durable medical equipment and home safety modifications. Jean presents as the type of client who would benefit from multiple services, more specifically, services that would benefit the elderly, women, sexual assault survivors, low-income individuals, and those seeking companionship.
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As stated above, Jean would benefit from multiple services, however, according to a small study conducted in 2023, “…
Case management guidance based on Maslow’s theory for stroke patients can improve patient rehabilitation outcomes and satisfaction with care.”
(Wang et al., 2023). Therefore, Jean’s physiological needs should be addressed first. To ensure the best possible outcome, a human service professional could refer to guidelines set by the American Heart Association. This document entitled, Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association, contains an extensive guide for health care professionals to apply the best medical standards with evidence-based strategies. The guideline states that, “Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential. (Winstein et al., 2016)” Furthermore in a study conducted by the University of Texas, it was reported that survivors who were better informed about their stroke and prognosis had less depression and made better functional recoveries than poorly informed patients (Ostwald et al., 2008). When considering these guidelines and studies, Jane would be best served by an interdisciplinary team made up of healthcare professionals who communicate and update each other regularly. Furthermore, in addition to assessing her home for safety, obtaining durable medical equipment, and intensive physical therapy in her home, Jean and
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anyone who would be willing to assist her during her recovery should be educated about strokes, the benefits of rehabilitation, the importance of compliance with the exercise regimen, and strategies for preventing another stroke.
Once Jean’s needs for her mobility issues have been coordinated, her history of PTSD because of sexual trauma should be addressed next. It’s also important to note that ischemic stroke victims often suffer depression or behavioral changes after an event due to injuries to the brain. When Jean’s mental and emotional health is evaluated, it would serve Jean to consider her as a whole person and not just PTSD as a single issue but that other contributing factors or comorbidities could exist. In Evidence-Based Practice With Women: Toward Effective Social Work Practice With Low-Income Women, has found that results of nonsystematic and systematic reviews indicate that the most effective interventions in treating PTSD are trauma-focused cognitive behavior therapy (Markward & Yegidis, 2011). It will be necessary to add a health care
professional with the skills to administer trauma-focused CBT to the interdisciplinary team and ensure that Jean is not only addressing her PTSD but any other mental health issues that may exist.
After assessing Jean’s well-being and identifying which issues will need to be addressed, it is possible that complexities regarding Jean’s care could arise. As previously stated, Jean was diagnosed with PTSD prior to having a stroke. This previous trauma coupled with mental health and behavioral changes often seen in stroke survivors could pose significant challenges to the clinician evaluating Jean’s mental well-being. Due to depression being a lead contributor to poor recovery outcomes after a stroke, it will be of the utmost importance that Jean’s mental and emotional health is assessed and any recommendations begin while Jean is still in the hospital (
How Common Is Depression after a Stroke?
, 2023). Another complexity that could occur in
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regard to Jean’s previous trauma is the possibility of being distrustful or uncomfortable around male medical professionals that might be included in Jean’s interdisciplinary team. Having an unfamiliar male presence without first ensuring Jean’s comfort could retraumatize the patient. When possible, having Jean interact with female staff during her stay as an inpatient while slowly introducing male staff as she expresses comfort could be helpful in avoiding further emotional distress.
Prior to Jean’s discharge from the hospital, it would be beneficial to address any financial
needs to ensure a smooth transition and decrease stress surrounding finances. Due to Jean already receiving social security, it is safe to assume she already has some type of Medicare, as the programs coincide (Medicare, 2023). However, since this coverage has proven inadequate, it would behoove Jean to have supplemental insurance to cover any other healthcare costs. If Jean is experiencing a large gap of coverage from the Medicare plan, she is already subscribed to, it’s possible that she only has Part D which only covers emergency care and prescriptions. Due to Jean’s age, she will qualify for Medicare Part A and Part B, which covers hospital stays, outpatient care, home care, preventative services and durable medical equipment. Jean would greatly benefit from obtaining Medicare as Manchester Community Hospital can retroactively bill for any services that she received for up to 12 months after discharge (Medicare, 2023).
In addition to federally funded insurance, New Hampshire has several programs that are funded by the state that Jean qualifies for such as Old Age Assistance which provides financial or medical assistance to those over the age of 65 or Medicaid which pays for certain health care costs for the elderly or those requiring long term care (
NH EASY Gateway
, n.d.). In addition to these state run programs, Jean could also benefit from support from various local agencies such as Catholic Charities New Hampshire, Acquired Brain Disorder Services, Administration on
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Aging, NHCarePath, and Easter Seals (
NH EASY Gateway
, n.d.). All these agencies provide support to the elderly or disabled with the mission of helping them live independently, address life’s challenges and reach personal goals. Connecting with these agencies and setting appointments prior to Jean’s discharge will help decrease any stress due to financial burdens, limited mobility, and ensure a smooth transition to her home.
In order to ensure the best possible outcome for Jean, it is essential to coordinate an interdisciplinary team of healthcare professionals that show mutual respect and understanding towards one another; ongoing coordination of efforts; and open communication between the team members, the patient, and the patient’s family (L et al., 1986). It is common for an interdisciplinary team to include physicians such as a hospitalist or primary care physician; specialty physicians such as neurologists, psychiatrist, or physiatrists; physical, occupational, recreation or speech therapists; dieticians; social workers or case managers; and nurses. Assuming Jean has been transferred to an acute stroke unit, a vascular neurologist, or attending physician, will lead the medical team in regard to Jean’s care while she is an inpatient. The attending physician is responsible for making decisions on diagnostic testing, appropriate treatments and searching for solutions to prevent future strokes. It is possible that other consulting physicians will be included in Jean’s inpatient care such as a surgeon if Jean needs surgery to remove any blood clots that could have caused the stroke. The attending physician might also consult with Jean’s primary care physician to gain insight into Jean’s medical history and collaborate as Jean’s PCP will be responsible for leading the interdisciplinary team after she is discharged from the hospital. Due to Jean’s history of PTSD and the effects that a stroke can have on a patient’s mental and emotional well-being the attending physician may want a psychiatrist on the team to assess Jean’s current mental health status as well.
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In addition to physicians, Jean will have various therapists included in her interdisciplinary team. According to The American Heart Association, it is recommended that physical and/or occupational therapy begins as soon as the patient is able to tolerate it as studies have shown that early intervention is critical for best patient outcomes (
Recovery after Stroke
, 2023). Physical and occupational therapists will work with Jean daily while she is an inpatient to help regain function on the left side of her body as well as educate her on how to function with limited mobility. While Jean stays in the acute stroke unit, it is possible that Jean may undergo physical rehabilitation more than once and nurses that specialize in stroke care will assist Jean with her therapy regimen in addition to others needs such as administering medications and assisting Jean with activities of daily living.
Patients who are admitted to acute stroke units will often require extensive rehabilitation and other services such as financial, meal, or housing assistance once they are discharged from the hospital. To help offload that burden from the patient, either a social worker or a case manager will join the interdisciplinary team to help patients and families with any challenges that
may occur from a hospital admittance and the resulting disability that can occur after suffering from a stroke. While Jean is an inpatient a social worker can help Jean with searching for a more suitable and affordable health insurance option such as Medicaid and Medicare; coordinate with agencies in preparation for Jean’s discharge from the hospital; collaborate with other members of
the interdisciplinary team to find affordable options for required durable medical equipment or safety adjustments to her home; update family members with any pertinent information; use strength based methods and goal setting to help Jean through the long recovery process; and various other tasks to ensure a smooth transition upon discharge. It is also possible that in lieu of
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a psychiatrist, a clinical social worker could also assess Jean’s mental and emotional well-being and provide treatment.
A social worker or case manager is responsible for improving the patient’s outcome and advocating on the patient’s behalf. In Jean’s case, there is a significant financial burden that arose due to insufficient medical insurance coverage, a social worker could help with finding cost-effective solutions. An example of a solution to Jean’s finances could be that the social worker contacts a local agency that would be willing to donate durable medical equipment or a charity that is willing to adjust Jean’s home for safety. Another example could be that the social worker coordinates with either Meals on Wheels or Catholic Charities New Hampshire for assistance with meals or obtaining other household items. A social worker could also look into agencies that provide in home therapy or home care that is covered by Medicaid such as Easter Seals or Community Bridges.
In a study conducted by the University of Texas, it was reported that stroke survivors who were better informed about their stroke and prognosis had less depression and made better functional recoveries than poorly informed patients (Ostwald et al., 2008). Therefore, it is critical
that Jean understands all aspects and outcomes of her discharge plan upon release from the hospital. Before Jean is discharged each team member should check in with the patient, as well as the patient’s family members, to verify understanding of follow up care at home such as prescribed medications, rehabilitation, and lifestyle changes while stressing the importance of compliance to ensure the best possible long-term outcome. One strategy that the team could use to ensure understanding is the teach-back method which entails the patient stating back instructions given in their own words. Another strategy that could help Jean with understanding of her prognosis and discharge plan is to take advantage of her organization skills. A social
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worker or a nurse could assist Jean with organizing a folder or notebook with all the information about her care and rehabilitation in a manner that makes sense to her.
When preparing for any patient to leave the hospital after an admission, it is crucial that the discharge planner apply best practice standards that include “early discharge planning, patient
and care support engagement and education, established follow-up, consistent and timely communication of pertinent medical information, and standardized discharge planning (Lewis, 2022).” Doing so will ensure that 87-year-old Jean will transition from inpatient care to community living in a safe, realistic manner intended to prevent future hospitalizations and provide the patient with the best possible outcome. Upon completion of assessments performed by Jean’s interdisciplinary team, it is evident that she will require multiple interventions upon discharge. Included in the tables below is an overview of her needs as well as strategies to solve these issues. Issue
Strategy and Agency/Source of Services
Hemiplegia
Per the American Stroke Association, “r
ehabilitation services are the primary mechanism by which functional recovery and the achievement of independence are promoted in patients with acute stroke (Winstein et al., 2016).” Considering this finding within the American Stroke Association’s Best Practice Guideline, it will be critical for Jean to obtain rehabilitation services upon discharge in either an inpatient or home care setting at an intensity appropriate with anticipated benefits and the patient’s tolerance. Physical therapy will be most beneficial to Jean to regain movement, balance and coordination. She would also benefit from occupational therapy to relearn the skills needed to perform everyday activities such as eating, drinking and swallowing, dressing, bathing, cooking, reading and writing, and toileting. Both these types of therapists will be able to assess the safety of Jeans home and make recommendations for modifications before discharge. It will be necessary to include Jean’s three adult
children in the decision about where she will obtain rehabilitation services because it is unclear if they will be able to stay in Manchester to provide home Client Needs (Including Financial) from Case Study
Issue 1: Stroke survivor with left sided hemiplegia
Issue 2: Previous diagnoses of PTSD due to sexual assault
Issue 3: Insufficient health insurance coverage
Issue 4: Financially insecure due to limited income sources and medical debt
Issue 5: Resides alone with no close relatives who live nearby
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care. If Jean requires an inpatient rehabilitation setting, she could consider Northeast Rehabilitation Hospital or Catholic Medical Center Rehabilitation in Manchester, NH. If one of Jean’s children can temporarily reside with Jean, education and support for that family member will need to be provided as well as rehabilitation that can be provided in a home setting. Many agencies in Southern New Hampshire provide physical and occupational therapy within a patient’s home such as Community Bridges and Easter Seals. Once Jean achieves the level of mobility necessary, outpatient rehabilitation services can continue with any of these agencies. Lastly, most patients do not comply with dietary and exercise guidelines, directives to stop smoking, and self-monitoring unless special attention is given to adherence therefore it will be imperative to use multicomponent strategies including patient education, goal setting contracts, self-monitoring, social support, telephone follow-up, and tailoring the
educational content to Jean and her family in order to ensure compliance of therapy regimens (Ostwald et al., 2008). PTSD
Jean’s medical history revealed a previous diagnosis of PTSD as a result of a sexual assault that occurred in her home. This prior trauma coupled with her current lack of mobility has caused Jean’s mental and emotional well-being to decline. Furthermore, stroke survivors often suffer from depression, anxiety or behavioral changes. Due to recent studies showing that traumatic stress predicts
stroke and
is also linked to many major stroke risk factors, it is imperative that Jean continue with trauma-focused cognitive behavior therapy that should have begun while she was still an inpatient (Perkins et al., 2021). While it would be ideal for Jean to continue psychotherapy with her inpatient counselor upon discharge either through telehealth or in an outpatient setting, it is possible that community resources may need to be utilized. Luckily, New Hampshire has a multitude of Community Mental Health Centers (CMHCs) which are private, full-service clinics that offer a wide variety of therapeutic services including specialized programs for older adults and community-based rehabilitation services (
Mental Health
, 2023). In addition to t-fCBT, Jean could also benefit from a peer support agency. Peer support consists of supportive interactions based on shared experience among people and are intended to assist people to understand their potential to achieve their personal goals. Peer support services include but are not limited to: face-to-face and telephone peer support; outreach; monthly educational events; activities that promote self-advocacy; wellness training; after hours warm line; crisis respite (
Mental Health
, 2023). It is hoped that Jean’s ability to manage symptoms of PTSD and improve her emotional well-being will not only prevent another stroke but ultimately improve her quality of life. Insufficient health insurance coverage
Due to Jean receiving a pension and social security benefits, we can assume that
Jean’s health insurance is federally run Medicare which has proven to be insufficient. To help Jean cover medical expenses that were incurred while she was hospitalized, it would be prudent for the hospital billing department to appeal any denials directly with Medicare. It would also behoove Jean to apply for supplemental coverage, such as Medicaid or a private insurance company. Due to Jean’s age and income, she qualifies for Medicaid coverage through the
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state of New Hampshire. Additionally, the social worker or case manager who is assisting Jean can also utilize the Centers for Medicare and Medicaid Services website that lists all services, tests or equipment that is covered by these insurances (
Medicare Coverage Database – Overview
, 2018) Use of this tool will help to avoid facilities or services that might not be covered by these programs, preventing further medical debt being incurred by Jean. Financial insecurity
Prior to Jean’s stroke, it has been noted that income from a pension and social security benefits barely covered her living expenses. Unfortunately, her entire savings account has been drained in an attempt to keep up with medical debt and Jean finds herself without the financial resources to pay for housing, food, or utilities. There are several agencies and programs that will be able to assist Jean with financial support so that she may continue to live at home. Per the Department of Health and Human Services guidelines, Jean qualifies for Old Age Assistance which is a state supplemental program that assists with rent and utility payments; Supplemental Nutrition Assistance program which gives participants a monthly allowance to purchase food at grocery stores; home delivered meals; and transportation services
(
Adult & Aging Care
, 2023). In addition to applying to federal or state run programs, Jean might also benefit from Southern New Hampshire Services, which is a locally operated Community Action program that helps qualifying residents with emergency rental assistance, utility payments and food assistance
(
Southern New Hampshire Services - Helping People, Changing Lives | SNHS
, 2023). Another resource that Jean could benefit from is Catholic Charities of New Hampshire which offers a wide range of services including financial assistance for housing or meals
(
Services
, 2023). It has been noted that Jean’s Catholic faith is a source
of comfort to her, therefore utilizing a Catholic charity could garner a positive response. Resides alone
If Jean’s children are not able to remain in Manchester while Jean regains functionality, she may not be able to safely return home and should consider an inpatient rehabilitation facility. However, if one of Jean’s children is able to temporarily reside with her, they will need to receive extensive education about Jean’s condition and how to assist her with activities of daily living. If Jean’s children are unable to provide the support needed, Jean may qualify for one of New Hampshire’s three programs that provides home based services with the intent of assisting people with living independently with safety and dignity for as long as possible. These programs are funded through the Older Americans Act, Social Services Block Grant, and the Medicaid Choices for Independence Waiver program (
Home and Community Based Care
, 2023). Though spots for these programs are limited, Jean does qualify. Another option for Jean is home care performed by Visiting Nurses Association or Catholic Charities of New Hampshire. Both agencies can provide not only assistance with Jane’s activities
of daily living, but also physical and occupational therapy; assistance with medication and rehabilitation compliance; and nursing services. If Jane resides alone, her mobility and concerns for safety are critical. However, Jane could also become lonely if she is unable to leave her home as she wishes. Catholic Charities of New Hampshire can provide Jean with a companion to visit her and
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take her on errands. Interaction with a friend or someone who is not there to provide care could help Jean’s emotional well-being as pre-stroke she was social with a group of friends and belonged to several clubs. Effective discharge planning can help reduce medical errors during transitions of care, which is known to be a time during which patients are particularly vulnerable. Planning for discharge should involve the patient and caregiver and begin as soon as possible during the hospitalization (Bajorek PharmD & McElroy, 2020). By follow this recommendation of beginning discharge planning promptly while including Jean, she is empowered to take part in her own care and make decisions on her own behalf. Granting Jean this autonomy will not only improve her self-esteem, being a part of the planning process whilst she is still an inpatient will decrease stress post-discharge and ensure a smooth transition of care. Furthermore, financial insecurity could have significantly impacted Jean’s ability to recover from her stroke due to financial barriers limiting access to necessary services. It will be a comfort for Jean to know that she will be able to continue to live in her own home and will have access to both equipment and services that will be financially covered by either her insurance or another agency. The discharge from a hospital is a critical juncture, when decisions are made that may influence the rest of that person's life (Potthoff et al., 1997). Therefore, it is extremely important that Jean adhere to any recommendations or guidelines provided by the interdisciplinary team as well as understand her current medical status. It is also necessary for members of the interdisciplinary team to regularly update one another and Jean to ensure compliance and progress. While Jean may have permanent left-sided hemiplegia or hemiparesis, it is hoped that she will gain enough functionality to live independently. Jean must also continue work with a mental health counselor who can ensure that she is coping well with the aftermath of a major
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medical event and the symptoms of PTSD. By continuing to improve Jean’s psychological well-
being, hopefully Jean will gain enough mental fortitude to overcome past trauma and decrease stress around her current circumstances. Lastly, Jean will not have to worry about financial burdens while she is recouping, allowing her to focus fully on regaining functionality, independence, and dignity. Through the process of developing Jean’s collaborative care plan, I based majority of my decisions on extensive research into evidence-based strategies that would give Jean the greatest chance for the best possible outcome. Due to the evolving nature as well as high costs of healthcare in the United States, I tried to make sure that each of Jean’s problems was addressed with multiple solutions should cost be a limiting factor in receiving services. While Jean’s Medicare plan provides her with basic health insurance to promote access to care, it is not an all-
inclusive comprehensive and free medical plan for the elderly poor and near poor. Financial concerns can still impede access to needed medical care, especially for those who have the most health needs (Rowland & Lyons, 1996).
To avoid any financial hurdles that could impede Jean’s recovery, I made sure that she not only utilized the appropriate “parts” of her Medicare coverage but also sought dual coverage from either Medicaid or a private supplemental insurance. Furthermore, I also gave recommendations for local agencies and charitable programs that can cover any outstanding financial gaps. My hope is that should Jean’s insurances funded by both the Federal and State government prove to be inadequate, or should there be a change in policy, that Jean will still have access to recommended medical care and therapies outlined in her discharge plan. The evolution of the United States’ healthcare system could impact Jean’s care in both positive and negative ways. Prior to the creation of Medicare and Medicaid in 1965, only private
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insurance was available for patients to purchase, causing the elderly, the unemployed and the poor to rely on their own resources, limited public programs, or on charity (Shi & Singh, 2023)
. Had Jean suffered a stroke prior to 1965, it is likely that she would not have had the means to pay
for her inpatient care or the extensive rehabilitation and recovery services that she requires. Since
Jean is eligible to receive federally funded health insurance, it is unlikely that she will be left with significant medical debt. Furthermore, access to medical care and affordability are not the only positive outcomes of the evolution of the U.S. healthcare system. Jean has also benefited from the Federal, state, and local governments imposing regulations, compliance and quality control for facilities and individuals who provide healthcare services. While some have argued against government involvement in healthcare, imposing rules and guidelines has been found to improve healthcare quality and ensures safety. Examples of proposed federal actions to reduce medical errors and enhance patient safety are provided “…to illustrate the 10 roles: (1) purchase health care, (2) provide health care, (3) ensure access to quality care for vulnerable populations, (4) regulate health care markets, (5) support acquisition of new knowledge, (6) develop and evaluate health technologies and practices, (7) monitor health care quality, (8) inform health care decision makers, (9) develop the health care workforce, and (10) convene stakeholders from across the health care system
(Tang et al., 2004).”
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