Real Life Rehabilitation

Louis Silver was faring well for a 93-year-old who recently lost his wife. He was living independently, with the help of a home care aid who provided cooking, laundry and driving assistance. But then he fell trying to pick up his watch, broke his hip and ended up in the hospital. The day after hip surgery Louis suffered a heart attack.

After three days in intensive care the hospital informed Louis’ son, Bob, that Louis was being released to go home. “I couldn’t imagine how he was going to go home in his frail condition,” Bob recalls, “so I called in a care manager for help.”

Based on Louis’ chart information, the hospital staff had determined that Louis could go home on his own, according to Bob. But as soon as the care manager evaluated Louis and read his chart, she insisted that the hospital conduct a physical examination. “She said there was no way my dad could go home alone, so she spoke to the hospital’s rehab case manager, got him a physical evaluation at which time the hospital changed its recommendation.”

“My dad would have died if he had gone home at that point,” says Bob. “We wouldn’t have known how to get him out of the car or that he needed a hospital bed and other supplies at home. There was no way the caregivers at home could have coped without the direction of a professional. They needed to be trained for proper transfer and they are only allowed to lift 25 pounds anyway.”

_{Living in a different world}
“The care manager helped me to understand that now my dad was living in a whole different world,” says Bob. The broken hip and heart attack had changed Louis from a relatively functional elderly person into a disabled elderly person, and at age 93 Louis needed to re-learn some of the basics.

“Patients need to realize that they have to learn how to live with a disability,” says Donna P. Jernigan, MS, BSN, RN, CRRN, CNA-BC, Medical Case Manager, Carolina Case Management, and Louis Silver’s care manager. “They need to learn a different way to do things that they have been doing every day of their life.”

After working for 34 years as a rehabilitation nurse, Jernigan realized that there was a breakdown between hospital care and home care. She became a care manager to help bridge that gap. Physical therapists often think about their treatment as just therapy, notes Jernigan, which can limit the progress for patients, particularly elderly patients living at home. “We have to think about these patients in terms of their functional status, and move them toward activities that are meaningful to them, such as getting a haircut or going to the grocery store. If we think of rehabilitation as a process and not a therapy we suddenly have a whole different approach. That has been my mantra for years.”

_{Identifying the essentials}
Care managers can help acquire all the essentials for a patient’s recovery, from medications to toilet seats, and assist with Medicare and other insurance. “We needed help getting all his medications managed and we needed very specific supplies,” says Bob. “Dad was initially prescribed a wheelchair, toilet seat and shower chair, and the care manager let us know that we also needed a hospital bed. All those things were covered by Medicare but we needed a prescription for them.”

The care manager also typically knows all the right questions to ask during doctors’ visits, and can facilitate communication between doctors. Jernigan now accompanies Louis to the numerous doctors he needs to see including the cardiologist, urologist, orthopedist and internist. “The doctors don’t typically talk to each other, so they don’t know if the medication they are prescribing is counter-indicated with a medication one of the other doctors is prescribing,” Bob notes. “This is a big problem with eldercare. Too often there is no one to coordinate the care.”

“Having a coordinated approach to medicine is critical in these cases,” Bob continues, “especially when children and other family members live out of town.” In addition to coordinating Louis’ care, the care manager communicates with the out-of-town family members. “She gives us a written report on everything that happens. That is very comforting to us.”

_{The road to medical and psychological recovery}
The medical care management is first and foremost, but once that is under control the psychological recovery also is critical. “I try to meet patients wherever they are psychologically,” notes Jernigan. “Louis wanted to eliminate his medications but it wasn’t the right decision, so I sat down with him and discussed all he’d accomplished since coming home from the hospital. We looked at his progress together and by the end of our conversation he asked ‘Do you think I need to be on these medications?’ and accepted my ‘Yes’ response.”

“As my dad has been getting stronger physically, the care manager started to treat him on the emotional aspect of his recovery,” Bob explains. “She arranged to get him out of the house to the barber. He was like a kid in a candy store the day he went out for the first time in weeks. It is unbelievable what the care manager was able to accomplish!”

Louis was hospitalized again on Sunday, October 5, 2008. Donna Jernigan continued to help Louis’ family manage his care. On Wednesday, October 8, Louis passed away with his son, Bob, and his caregiver, Dorita Free, by his side.