Question

You have been asked, as a digital health professional, to attend a team meeting at your hospital to discuss discharge plans for Mildred Mason. She is a 68 year old widow, hospitalized for a fractured wrist and ankle and a head injury resulting from a fall at home.   She is almost ready for discharge from acute care, but the team is concerned that she will need care in the short term. Because of some problems that may have led to the fall and may cause more difficulties in the future, the team also foresees she will have increasing needs in the future. While a short term admission to a senior care facility until she can function independently has been suggested, Mildred is adamant that she will not go to a long term care facility, even on a short term basis. She fears she will be “warehoused” and never go home again. The team hopes they can integrate digital devices into her care to help her to stay at home safely.

Mildred is a retired school teacher. Her husband died 4 years ago of a heart attack. She lives alone in a 2 bedroom condominium apartment with laundry facilities in the unit. Sandra, who lives down the street, has been a good friend to Ms. Mason for many years and visits daily. Ms. Mason is very active in the community, helping raise money for United Way, organizing her church’s Christmas craft sale, belonging to a book club, and going to exercise classes twice a week. At the exercise class, she had complained to the instructor that she found she was having increasing problems with balance. She has a pension that allows her to live comfortably and take a trip each summer to visit her two sons and their children in BC and the Yukon. She uses weekly Skype calls to keep in touch between visits.

She has had Type 1 diabetes since she was 10 years old. Her diabetes has been well controlled until recently, but the diabetes educator at the hospital clinic she visits regularly is concerned that she sometimes seems to be forgetting to monitor her blood sugar or to refill her insulin pump completely.   Last week, Ms. Mason slipped in the bathroom, fracturing her right wrist and left ankle, and sustaining a head injury that caused her to lose consciousness for a few minutes. She had her cell phone with her and was able to call 911 when she regained consciousness. She now has a cast on her right wrist that will be on for 6 weeks. She had surgery to insert pins in her left ankle and will not be able to weight-bear for several weeks. She still complains of pains in her head from the concussion. She has been going to Rehabilitation in the hospital for physiotherapy, but her mobility is hampered by the cast and weight bearing restrictions.

Her neighbour Sandra has told staff she would be willing to help with things like groceries, but since she has two small children at home and a full-time job, she can only make brief visits. Sandra also expressed concern that Mildred has seemed “vague” lately, forgetting things and not taking as good care of the apartment as she used to. Mildred has also had many visits from friends who have reported they are planning to provide meals and regular visits when she goes home. The Home Care liaison in the hospital has been involved, but has indicated that only 3 hours a week of support for bathing, laundry and other tasks are likely to be approved. The nurses report that Mildred is adamant that she wants to return home. Because of concerns about how Ms. Mason can manage after discharge from the hospital, a team meeting has been called to plan for the future. As the team discusses options, they turn to you to find out if there are digital solutions to help Mildred return home on discharge and stay there as long as possible.

Questions to be answered in the assignment:

                                                                                           

1. What do you see as the main problem(s) faced by the patient & significant others, and the interprofessional team in this situation?
2. Which professionals should be involved in planning the discharge of this patient? Why?
3. Which health care providers should be involved in the on-going care of this patient? What should their roles be?
4. What other resources might be needed for discharge plans to be successful?
5. What role can a digital health professional play in this scenario?
6. What digital resources would you recommend?
7. How would you explain your role and recommendations to the team and to the patient?

Answer 1

*The main problem here is the fear and anxiety of the patient to get a short term care in predicting that she will be halted their on long term basis . Thus isolated from family, her homely environment, difficulty in adjusting at this age .

The others (Sandra) though a neighbour could offer only a brief visit to help Mildred only way th grocery due to lack of time and family responsibilities

The interprofessional team has a significant problem of giving a safe discharge predicting the risk of fall and further injury in home if left alone without any support.

*The procesionals who can be involved in planning the discharge of the patient are

• Social support worker who can help to arrange for required staffs like caretaker, personal support worker to meet her work done in home
• Home healthcare agency for the need of nursing aide service as she forgets to fill her insulin pump, overseeing her cast and any complications from it, medication overview

*The healthcare provider which is needed for ongoing care are

• Diabetologist to monitor anf keep her blood glucose under control
• Neurologist as she is complaining of pain from the concussion
• Orthopaedician for follow up and review of her fracture

*The other resources which might be needed for successful discharge plan is the use of digital technology to monitor the patient's condition after discharge

*A digital health professionals can play the following role

• To ensure the patient is provided with digital health service to access and use it
• To ensure there will be a proper communication channel between the patient and the health care team after discharge

*Telehealth or Telemedicine can be recommended for this patient

*Some of the ways to explain the roles and recommendations to the team and patient are by

• Explaining the technical need of connecting the healthcare sector to a patient's personal access
• Teaching the client in regards to the use of personal health records
• Device monitoring which can help to track patient' s vitals and blood glucose levels.