CIS Marys Care Nov 12 aWithin the main session room, four groups gathered to discuss Mary’s care transition story during the Wednesday breakout sessions at the 2014 Kindred Clinical Impact Symposium. Each group, consisting of around 14 to 18 participants, had a facilitator to help direct the discussion. The groups were made up of people from various disciplines from different types of facilities in different parts of the country.

 

The groups all had the same task: to look at the three parts of Mary’s care, recovery after stroke, cognition and nutrition, and evaluate what they felt went wrong and what could be improved, focusing on specific questions such as “would it have been better to conduct the Allen Cognitive Test earlier and why?” In Mary’s case, the test wasn’t performed until day nine. Across the groups, many of the participants emphatically said the test should have been performed earlier, if only to provide a baseline for future tests. One group noted, however, that with her impairments immediately after the stroke, administering the test might not have been possible.

One common theme that emerged was that, throughout Mary’s care, the focus was not on Mary or her goals. Many participants felt that led to a lack of understanding of the underlying reasons for some of Mary’s issues, such as her sleeplessness and lack of appetite. They also wondered if Mary’s worries over how her husband was faring were contributing to her slow recovery. One group felt that they didn’t have adequate information about Mary and that the neighbor who called 911 may have been a better resource for understanding Mary’s condition prior to the stroke instead of Mary’s daughter, who lived out of town.

In all of the groups, one or more of the members wondered why the care transitions manager (CTM) was called in so late and whether the CTM was for Mary or for Jack, as it was unlikely that Mary could continue to care for Jack and, as the daughter indicated, Jack wasn’t doing very well either. The majority felt the CTM should have been called in immediately to help ensure the continuity of Jack’s care since Mary was his primary caregiver.

Another common theme was that the group members felt that one solution to putting the emphasis on Mary was to re-examine how the facility’s interdisciplinary team meetings (IDTs) were conducted. Putting Mary at the center of the discussion would help reduce IDT meetings in which everyone reported from a checklist, but perhaps didn’t listen to what the other disciplines were reporting. If the IDT meetings were only task-oriented, the big picture view could be missed completely. One facilitator, Allen Johnson (Red Team), said it was like the man looking out from his yard to see two city workers, one digging holes and one filling them up. When the man asked the city workers what they were doing, one told him they were planting trees. Seeing the man’s confused look, the city worker added, matter-of-factly, that the guy who put in the seedlings had called in sick that day.

As the groups concluded the exercise, the consensus was that Mary had been, to some extent, forgotten in her own care, and that “fixing” this wasn’t possible with only the efforts of one person or one discipline. To put the spotlight back on Mary would require the efforts of everyone on her care team, and an improvement in overall communication both with Mary and her family and among the care team.