HSE 210 Final Collaborative Care Guide

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Southern New Hampshire University *

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Feb 20, 2024

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1 Final Project – Collaborative Care Guide Molly Strempfer Southern New Hampshire University HSE-210 X1247 Healthcare Systems Dr. Lena Klumper October 15, 2023

2 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.

3 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

4 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

5 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

6 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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