Case Management Of Frail - Elderly Stroke Survivors

The process of case management (CM) is an essential component of quality healthcare. The Case Management Society of America defines case management as follows: "Case management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individuals health needs through communication and available resources to promote quality cost-effective outcomes." (Case Management Society of America, 1995, p.8) "Case management is an intervention strategy used by health care providers and systems to advocate for clients, coordinate healthcare delivery, and facilitate outcomes of both cost and quality." (Huber, 2006). Zander best describes the process of case management as "the nursing process applied at a systems level" (Zander, 2002, p.58).

The CM process, which is often referred to as clinical resource management is addressed in the CMSA's Standards of Practice for Case Management (2002). This provides a guideline for case management and consists of assessment, planning, facilitation, and advocacy; all of which are core functions of the clinical case manager.

This case management plan is focused towards frail, elderly clients who have suffered a stroke and will be returning home upon release from their hospitalization, having care provided to them primarily by a family member.

You often hear the word acute when physicians refer to a stroke, this implies that the stroke is a short-term condition when in actuality; the implications of a stroke are long term and become chronic (Young, 2001). When a stroke is treated as just an acute condition, the clinical outcomes are not as great as if an evidence based model similar to that of a rehabilitation unit is implemented upon returning home from the initial admission (BMJ 1997).

The fastest growing segment of our population is the frail elderly, aged 85 and older (Hobbs 2001). As Clinical Nurse Leaders, it is imperative that we embrace the needs of this rising population and develop plans of care to best suite their ever growing needs; ones that address their quality of life.

Stroke survivors have residual neurological impairments, which require long-term support and care. "Stroke is the leading cause of long-term disability in the US with over one million Americans currently living with serious functional limitations. According to the National Institutes of Health, of individuals with stroke over the age of 65, approximately 50 percent will have persistent hemi paresis, 30% cannot walk without assistance, 19% have aphasia, 35% have depressive symptoms, and 26% require institutional care" (Brashers, 2007). Anxiety, depression and poor physical health are common effects among family caregivers of stroke survivors. There is also an association between the stroke survivor's level of disability and emotional state and the emotional distress of their caregivers (Bugge, 1999).

The American Heart Association (2005) identified family cooperation as an indicator for successful rehabilitation after a stroke. However, many family members take on the responsibilities of care giving in addition to their routine activities and work schedules. Primary caregivers who work must rely on other family members to assist with care giving responsibilities. The amount of care provided by a single caregiver can be reduced if responsibilities are shared; sharing the responsibilities requires that family members collaborate and communicate. Studies have shown that family relationships deteriorate after a member survives a stroke (Anderson, Linto, & Stewart-Wynne, 1995; King et al., 2002), and ineffective family functioning (families not communicating and problem solving well) has been associated with negative psychological outcomes for caregivers (Clark et al., 2004; Evans, Bishop, & Ousley, 1992).

Model

The Carondelet St. Mary's Community Nursing Network (Arizona) Model is a

hospital to community approach, across -the- continuum of care, and is the model best

suited to address the needs of the patient population and their families of frail elderly stroke survivors who choose to return home for rehabilitation

Assessment

In the assessment phase, the nurse will begin by assessing the needs of the patient; he/she will then work to develop the most appropriate plan of care specific to that particular patient and his/her needs. CMSA states in the Standards of Practice for Case Management (2002) that this assessment needs to cover health behaviors, cultural influences, beliefs / values systems and must include identification of potential barriers, negotiating realistic goals with the patient, and searching for alternatives when compromise cant be made. The U.S. Department of Health and Human Services recommends that a standardized Assessment Instrument should be used to facilitate the evaluation of the patient's actual performance of activities.

Planning / Facilitation

The planning and facilitation phases should be considered and approached as a collaborative measure where the patient, family, decision makers, medical / nursing staff and community resources are all considered. The nurse will begin to devise a care plan that is very individualized and focuses on evidence- based practices supported by solid research. In the plan of care, specific treatments will be identified as well as the sequence, intensity, and duration of each treatment. The initial plan may not be a success so it is imperative that fall back plans be in place in order to accommodate any sudden or unexpected breached in the original care plan. It is important for the case manager to streamline the care by maintaining and encouraging open communication between the patient, their family and other services that may be, or that are anticipated to be provided for this patient.

The case manager has the role similar to that of a social worker in that they will assist the patients and family in locating available community or private resources focused at helping to reduce the caregivers burden and provide quality of life for the patient. This is done by an individual assessment of the client and their family; taking into consideration the needs of both with the primary interest to that of the client.

Below you will find a list of appropriate local community organizations and interventions that may be beneficial for the needs of this client population. With the goal of meeting the clients immediate needs having been taken into consideration. These interventions will be discussed with the client and their family to choose the