Mary's Care Transition Story

By Kindred Healthcare
NOTE: Mary's story is purely hypothetical and was crafted specifically for 2014 Clinical Impact Symposium attendees to use as an exercise in care transitions. Any resemblance to a person living or deceased is coincidental.

Last year, at the Kindred Clinical Impact Symposium, participants followed the fictional story of patient Jack Marton, who suffered an accident and then faced a complicated recovery through several levels of post-acute care. This year, attendees will consider the case of Jack’s fictional wife, Mary, who serves as Jack’s primary caregiver. Mary and Jack’s children live in Utah and Pennsylvania, so Mary does it all – cooking, cleaning, running errands and taking care of Jack, including taking him to his doctor appointments, since home health has signed off the case.

As with many family caregivers, Mary hasn’t seen her own primary care provider since Jack fell ill. She has, in fact, canceled several appointments with him. She has some underlying medical conditions – including hypertension and old tobacco use.

Beginning tomorrow, as an exercise, participants, broken down into interdisciplinary care teams, will consider Mary’s case and try to figure out how it could’ve been managed better.