Transitional Care of the CVA Patient/Family ExperienceWe all know that family caregivers play a critical role in maintaining the gains patients make in post-acute recovery, especially after they transition to home. But truly understanding the complexity of the family caregiver role is crucial to ensuring that patients are in good hands, have the best chance at maintaining their gains and avoid returning to a higher level of care, all of which affect post-acute outcomes.

Eric Coleman, MD, MPH, AGSF, FACP, Director, University of Colorado Denver, has been a favorite speaker at Kindred’s Clinical Impact Symposium, and this year he returned to explore the family experience in the transitional care of the CVA patient.
 
Coleman referenced recent research that found that 46% of family caregivers reported performing medical/ nursing tasks – tasks that are typically described as skilled and delivered by clinicians. Seventy-eight percent of family caregivers managed medications. And 53% served as care coordinators.

Many of those caregivers have been improperly prepared for these roles. They don’t always know what is expected of them. Involving family caregivers from the start and making an effort to truly understand their preparedness and their expectation of their own roles is important to success, Coleman said.

If family members are not involved, they don’t know what is expected of them, he said. They have no opportunity to refuse or have barriers accounted for in care plans.

Family caregivers often need training and support. No one can absorb all information and instructions given at discharge without follow-up. Early preparation and post-discharge follow-up are key.

It is crucial to broaden our understanding of who or what a family caregiver is, and we must think outside the traditional definition, Coleman said. Assumptions may be wrong. Asking a patient, “who helps you with your medications?” is one way to elicit useful information. It may:

 

  • Not always be a relative
  • Not always be just one person
  • May be local or distant
  • May be role-specific
  • May change over time

From their vantage point, family caregivers may not always want to be known as “family caregiver” or “power of attorney.” Often they just want to be known as they were before – as a daughter or son, for example.

Coleman mentioned a Web resource that can help both clinicians and family caregivers in formulating successful care plans for patients: www.nextstepincare.org

Coleman also talked about the very important topic of cross-setting communication and information exchange.

When forming cross-continuum teams, Coleman said, it is important to acknowledge interdependence with an eye to language and standardization of communication (or at least developing an understanding of the language used by the other entity).
Care tools are developed in order to communicate important clinical information from one setting to the next.

Paying closer attention to the details regarding family caregivers, as well as forming effective cross-continuum teams, will help us improve care transitions, an important goal as the healthcare environment moves from volume to value-based care. Utilizing local expertise and sharing successful tools are important strategies as well.