Navigating Hospital Discharges with an Aging Life Care Manager

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Windward Life Care’s professional Aging Life Care Managers provide an array of services that benefit clients and their families. One particularly important function is assisting clients and their support systems in managing medical conditions and related problems. This includes helping clients and their families navigate through often stressful and confusing hospital visits, whether the visits are routine or urgent. Care managers like Windward’s Terry Ehlke, RN, BSN, CMC, serve as the client’s primary advocate to facilitate the entire process. Terry took some time out of her busy schedule to answer questions about some of the essential services a care manager provides at such critical moments in a client’s care.

Terry Ehlke, RN
Clinical Services Manager
Windward Life Care

How can Aging Life Care Managers help when an older or disabled adult is hospitalized?

Care managers function as patient advocates, making sure the client is cared for properly during hospitalization all the way through discharge. Care managers work closely with the client and hospital team to ensure everyone understands the history and special needs of the client, any unnecessary trips back are avoided (such as for tests that can be handled during the current visit), the client is safely discharged, and adequate discharge instructions are provided to the client and caregiver. A care manager can also step in with any appeals to pause or slow down the discharge process if need be. Often clients don’t realize they can say “no,” so they just go along. The ultimate goal is for clients to experience the safest and most effective and efficient hospital stay possible.

What are the risks when the hospital says it’s time for a patient to be discharged?

Unfortunately, the discharge process can often be too fast and disorganized. Without any standard of care for hospital discharge in place, every hospital does their own thing. Hospital staff are under great time pressure and can rely on “cookie cutter” discharge plans that don’t account for the client’s unique circumstances. The very real situation at the client’s home is often overlooked, so failures stemming from not considering certain bigger-picture issues are common. Elderly clients especially are very medically fragile. In addition, communication and referral delays can lead to unsafe situations at home and treatment delays. Instructions to the patient regarding follow-up care, if even provided, can be rushed and inadequate. This is particularly dangerous in the case of a new diagnosis for diabetes or congestive heart failure. There is a significant risk that problems that could have been easily prevented through a better discharge process will lead to readmission.

Why is preventing readmission such a big deal?

I recently read a study that revealed up to 27% of rehospitalizations were preventable. While it’s true that many readmissions are simply not avoidable, medical issues that are not resolved prior to discharge or failures in the transition to home can often result in an otherwise unnecessary return to the hospital or emergency department. Readmission has a huge impact on the client’s quality of life and safety. Each hospital visit poses that much more exposure to potentially lethal complications (medication errors, hospital-acquired infections, blood clots, etc.) while putting added stress on the client who is once again away from the comforts of home in an unfamiliar environment. Worsening cognition, including delirium, can result from being in the hospital environment. Ultimately, readmission delays recovery, possibly introducing new complications.

Who is most at risk for recurring hospitalizations/readmission?

There are myriad factors that increase the risk of repeat hospitalizations. These include taking certain medications, such as antibiotics, glucocorticoids, anticoagulants, narcotics, antipsychotics, and antidepressants to name a few, as well as certain chronic health conditions, like advanced chronic obstructive pulmonary disease, diabetes, heart disease, stroke, cancer, and depression, among many others. Prior recent hospitalizations and premature discharges also increase risk, as does low health literacy, a limited social network, and low socioeconomic status.

A key advantage of working with a care manager is that we have detailed knowledge of a client’s daily life, health, diet, medication regimen, and other circumstances that can impact his or her health and well-being when it comes to hospital readmission.

Medications can be confusing and the risks of taking them incorrectly are high. What can families do to help reduce errors and complications in this area upon hospital discharge?

The client and/or family caregiver must be clear on all medication instructions. Families and caregivers need to determine who will set up and manage the medications, as the client may not be the best person to do this for him- or herself. All medications, including pre- and post-hospital meds and over-the-counter meds, should be reconciled. Be sure to update and consult with the primary care physician as soon as possible following a hospital discharge. Due to the complexity of managing the administration of multiple medications at multiple times of day, enlisting the services of a home health nurse may be the best option. Pharmacists can also be an invaluable resource.

What are some of the issues where multiple healthcare providers are involved?

There are often many providers involved after a discharge. Inadequate hand-offs and communication problems between them are major impediments to a smooth transition to home. Home health providers, including nurses and therapists, may get incomplete information from the discharge planner’s referral. Equipment is ordered (or maybe not) and does not arrive on time. Home care aides are often not provided with basic information prior to working with a new client. There’s the potential for no one to follow up on hospital lab results after discharge if the discharge papers didn’t indicate any were pending. Pharmacies are also known to transcribe orders incorrectly, or not know some medications were discontinued or changed at the hospital, and then they don’t fill them correctly or at all.

Do doctors ever talk to each other about their shared patients?

Hospital doctors, or hospitalists, do not talk to primary care doctors as a general rule. This often comes as a surprise to our older clients who were used to a different system for most of their lives. Doctors may share computer records, but those are sometimes incomplete. Up to 50% of patients do not see their primary MD following a hospital stay, though this is essential to the success of ongoing care and is usually included in the “to do” list in discharge instructions. The hospital discharge planner typically does not make this appointment for the client. Referrals are mostly made to specialists, but if the client does not follow up to make an appointment, the specialist may never see the client.

What steps does a care manager take to ensure a smooth transition to home when a client is leaving the hospital?

This is often the time when we first get involved with a new client because the family or involved professional realizes they need an advocate. The Aging Life Care Manager conducts a full assessment that starts with a review of the discharge instructions. Particular attention is paid to any signs that require medical attention, medication changes, any restrictions on physical activity and diet, and any treatments that are needed. The care manager also follows up with the primary care physician and specialty providers while making sure the client and family have a complete understanding of all of the above and consults with them regarding possible needs for home healthcare assistance.

The care manager also discusses with the client and family meal preparation, physical and social activities, transportation needs, financial resources, and client preferences, because a care plan that does not align with the client’s preferences cannot be effective.

The care manager then develops a customized care plan based on this thorough and holistic assessment of the client. The plan addresses both immediate needs and long-term care goals, and it clearly identifies who is responsible for each service. The care manager communicates the completed plan with the client, family, caregivers, and other professionals who may be involved in the client’s care. The care manager then supervises the plan’s implementation.

 

Terry Ehlke recently presented on the topic of hospital discharge planning best practices at the San Diego Regional Home Care Council Spring Symposium in May 2019. Terry was recently promoted to the position of RN Clinical Services Manager at Windward Life Care and is available for assessments and consultation.

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Recommended Vaccines for Older Adults

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With all the recent news headlines about measles outbreaks and vaccinations, it’s a good reminder for people of all ages to evaluate their immunization schedule. Are you up-to-date on the immunizations required to strengthen your immune system against avoidable diseases?

Often, older adults assume that they don’t need to worry about this topic because of the vaccines that were given in childhood. The truth is that the CDC recommends a few key vaccines for seniors, helping you maintain optimal health in the later years of your life.

Recommended Adult Vaccines

The first step is to evaluate your immunization history with the recommended CDC adult immunization schedule. Your doctor can help you identify the vaccines that should be administered. Health professionals have found that protection from childhood vaccines can wear off with time.

These are some of the guidelines that should be considered to prevent the contraction and spread of serious diseases:

  • Seasonal Flu: The flu strain changes each year, which means that all adults should receive a seasonal flu vaccine. This immunization is most important for older adults, people with chronic health conditions, and pregnant women.
  • Measles: Outbreaks have been reported across the country, making it more important than ever to stay current with your measles vaccination. The CDC recommends that people born between 1957 – 1967 should be revaccinated now.
  • Tdap: If you did not receive a Tdap as an adolescent, then this vaccine is suggested to avoid the risk of whooping cough. Also, a Td booster is recommended every 10 years.
  • Shingles: Older adults have a higher risk of shingles contraction, which is why it is a good idea to have a shingles vaccine.
  • Pneumonia: This vaccine is recommended for adults 65 years or older, as well as children younger than 2 years old. People between these ages with specific medical conditions might also benefit from the pneumonia vaccine.

While illness and disease are a part of life, there are things that you can do to protect your health and avoid serious health concerns. Staying current with your vaccinations can be an important step in your overall health plan. Do you need assistance in designing a personalized healthcare plan or finding the right health care providers in the area? Windward Life Care is here to help. Call to learn about the available services.

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Maintaining Healthy Hearing: Prevention and Treatment Options

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Hearing loss is surprisingly common among older adults, with an estimated 33% of people between the ages of 65 and 74 suffering from this problem. Aging can contribute to these issues, as well as genetics, noise, and disease.

Hearing Problems Faced by Older Adults

Poor hearing in older adults isn’t only an inconvenience, but it can have a ripple effect on many aspects of life. When someone is experiencing hearing loss, they find it hard to hold conversations with family and friends. Additionally, hearing loss can increase the risk of depression, isolation, and even dementia.

Sometimes, a person suffering from poor hearing feels embarrassed or frustrated because they can’t understand what other people are saying. Friends and family might mistakenly think that the person is uncooperative, unresponsive, or confused when really the problem is with the person’s hearing.

Is it Time to Get Your Hearing Checked?

When hearing problems are ignored or left untreated, the issues will get worse with time. If you suspect that you have a hearing problem, then it is essential to visit a doctor for expert advice and treatments.

Signs of hearing loss include:

  • Difficulty hearing when talking on the telephone
  • It is hard to follow conversations when two or more people are participating
  • There is often a need to ask people to repeat their comments
  • Turning up the TV or radio to a point where other people complain about the noise
  • Unable to hear due to background noise
  • The perception that other people are mumbling

Technologies to Help with Hearing

The recommended treatment plan will vary depending on the severity and type of hearing loss that you are experiencing. Some treatments will work better than others. Available treatment options include:

  • Hearing Aids: Small, electronic devices worn behind or in your ear, helping to amplify sounds.
  • Assisted Listening Devices: Certain devices can be used to amplify the sounds coming through a cell phone or tablet. Additionally, closed circuit systems can be used in public locations, such as auditoriums, theaters, and more.
  • Cochlear Implants: These implants are placed in the inner ear and are often used when the hearing loss is severe.

Other treatment options include lip-reading training or even medications in some cases. If you need help finding the right medical support for your hearing loss, then our team is here to assist. Contact us at Windward Life Care.

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Chronic Kidney Disease – What Is Your Risk?

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Chronic Kidney Disease (CKD) is a growing public health issue, with an estimated 10% of the worldwide population affected by this condition. This lasting damage to the kidneys gets worse over time, especially without lifestyle changes and treatments to slow the disease. World Kidney Day is March 14th; this day is designated to spread information and knowledge about kidney health.

Your kidneys work hard to keep you alive each day. If the kidneys fail, then it is necessary to have a transplant or receive dialysis treatments several times a week. It is important to take good care of them, helping you maintain optimal health in all stages of life.

Symptoms of Chronic Kidney Disease (CKD)

In the beginning, you might not recognize that your kidneys are struggling. It is common for the symptoms to start slowly and get worse with time. When the symptoms are recognized, it might be that your kidneys are already severely damaged.

If your kidneys are struggling, common symptoms include:

  • Muscle cramps
  • Itching
  • Reduced hunger
  • Swelling in the ankles and feet
  • Changes in urine output
  • Difficulty catching your breath
  • Trouble sleeping
  • Vomiting and nausea

The best thing you can do is contact a doctor as soon as possible if you notice these symptoms.

Risk Factors for Kidney Disease

Genetics and age play a role in the development of kidney disease. For example, if you are over the age of 60 and have a family member with kidney disease, then your risk is high. Doctors have also found that other health issues increase the risk of CKD:

  • Diabetes
  • Heart Disease
  • Hypertension (High Blood Pressure)

If you’ve been diagnosed with one or more of these conditions, don’t overlook the importance of managing the disease to keep your kidneys healthy. Lifestyle changes and proper treatment can improve overall health and have a positive impact on your kidney health as well.

Do you need help finding the right health resources and medical care? At Windward Life Care, we are working hard to ensure that you have the support needed to live a healthy lifestyle. Contact us to learn about the services that are available.

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World Cancer Day: 5 Tips for Early Detection and Prevention

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February 4th is world cancer day: a reminder for people of all ages to minimize the risk of cancer by improving healthy habits. Even though cancer is an increasing concern around the world, there are things you can do to reduce your risk.

Tips for Lowering Your Risk of Cancer

Today, we are sharing tips from the American Cancer Society and the Centers for Disease Control to help you make incremental changes that will decrease the risk of cancer:

  1. Maintain a Healthy Weight: Did you know that obesity is linked with the development of cancer? Not only does it feel good to maintain a healthy weight, but losing weight is beneficial to avoid life-threatening diseases such as heart disease and cancer. Choose a healthy diet and maintain a consistent exercise routine to let go of the excess pounds.
  2. Sun Protection: The most common type of cancer in the United States is skin cancer. UV rays from the sun can damage the skin and lead to cancerous growth. Never use tanning beds and be careful when spending time outdoors. In the mid-day, look for shady areas, wear clothing that offers sun protection, and apply sunscreen every 60 – 90 minutes.
  3. Avoid Tobacco: Researchers estimate that 80 – 90% of lung cancer deaths are caused by smoking cigarettes. Additionally, the risk of many other types of cancer increases for smokers: throat, mouth, stomach, colon, bladder, cervix, kidney, liver, larynx (voice box), and more. Quit smoking to be proactive in avoiding a cancer diagnosis. Also, stay away from secondhand smoke whenever possible.
  4. Limit Alcohol: Links have been found between alcohol consumption and various types of cancers: voice box, mouth, throat, liver, and breast cancer. Minimize alcohol consumption or avoid it altogether.
  5. Vaccinations: Hepatitis C has been connected to the development of liver cancer. This disease causes inflammation in the liver, leading to cirrhosis, liver failure, or liver cancer. An easy solution to prevent liver cancer is to stay current with vaccinations to prevent Hep C.

Age is another factor that can affect the development of cancer. Everyone ages, so this factor can’t be avoided. But it is important to tap into resources that are available for assistance if you are facing cancer treatments in the later years of life. Our team at Windward Life Care is here to help you locate the best resources for your needs. Contact us to learn about the services that are available.

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Summer Heat Safety for Older Adults

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The heat can be uncomfortable for people of all ages, but older adults are prone to heat stress, which can be a dangerous situation if left untreated. As a result, seniors can experience several heat-related health problems when the weather warms up outside.

Whether you are caring for your own health or you are a caregiver for another adult, it is important that you are proactive to stay safe in the heat.

Why Older Adults are at Risk

Why is the risk higher for older adults? Often, seniors have medical conditions that affect the body’s ability to regulate temperature. Some chronic conditions can change the body’s response to heat.

Certain medications might have an impact on how the body sweats. For example, diuretics can increase the risk of dehydration due to water loss. Heart disease impacts the blood circulation, which makes it harder for the body to dissipate the heat.

Older adults’ sense of thirst also diminishes with the aging process. Feeling less thirsty, combined with some seniors’ difficulties with incontinence, can lead many people to avoid drinking water and other fluids. This increases their chances of becoming dehydrated which can lead to hospitalization.

Prevention is Important

Don’t wait for symptoms to occur before taking action against the heat. Being proactive is the best solution to prevent health complications:

  • Stay in an air-conditioned area as much as possible during the day.
  • Increase water consumption. Drink consistently throughout the day instead of waiting until you are thirsty.
  • Wear clothing that is loose-fitting and light in color.
  • If you are feeling warm, take a cool bath or shower to lower your body temperature.
  • Minimize physical activities, especially when you are spending time outside.
  • Use window coverings to keep the heat of the sun out of the room.
  • Turn on the air conditioner, even if it increases the utility bills; or, go to a public library, indoor mall or San Diego County-sponsored “Cool Zone.”
  • Avoid caffeine and alcohol which can increase the risk of dehydration.

If you have an aging neighbor or family member, then it is smart to check in regularly to make sure they are staying cool. In the situation where the power is lost, it is essential to offer assistance to help the person get to a cooler place.

When to See a Doctor

Certain symptoms might indicate that it is necessary to see a doctor: strong or rapid pulse, feeling faint, confusion, increase in body temperature, or dry, flushed skin.

Whether you have questions about heat-related symptoms or you need assistance with other medical concerns, Windward Life Care is here to assist. We can help you find the right resources to match your needs. Call to learn about the services that we provide.

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