Leading Change at the Local Level - Continue the Impact

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.  

Throughout the 2014 Kindred Clinical Impact Symposium: Clinical Excellence in the Care of the Stroke Patient Across the Continuum, participants were asked to consider the fictional case of Mary Marton, a 66-year-old woman who had been the primary caregiver for her debilitated husband, Jack, until she herself suffered a stroke. Participants broke into small groups yesterday to talk about some of the lessons learned through the care Mary received after a friend called 911 when she noted Mary’s speech was slurred and that she was having trouble picking things up off the table.

Mary was diagnosed with a discrete hemorrhagic stroke on the left side. In the acute care hospital, Mary’s appetite was poor, and an NG tube was placed and maintained for several weeks until Mary’s weight stabilized. On Day 7, she was transferred to a skilled nursing facility for rehab and medical management.

At the skilled nursing facility, Mary was observed to be frail and restless, and could not perform her activities of daily living independently. Her appetite was still poor. She had several medication orders. A swallow study was ordered.

Back at home, things were going poorly. Mary’s husband, Jack, was spending a lot of time unsupervised with his personal hygiene suffering. A transitional care manager was brought in to assist with finding solutions for Jack.

Mary developed pneumonia at the nursing center. A Modified Barium Swallow revealed dysphagia, but the NG tube was removed regardless, and a pureed diet with thickened liquids was introduced. Mary complained about the food and when her son’s family visited a few days later, she attempted to eat a chicken nugget and choked. A GI tube was recommended, to remain in place after transfer home, but the family was resistant, and overwhelmed in general.

Some of the comments to come out of the break-out groups included:

  • We failed Mary. We potentially have so much impact but we have to improve
  • Do we attack each other? Are there bad feelings or turf wars between levels of care? We are one big team and need to support each other that way
  • The family should’ve been vetted, to find out what they want
  • There was a breakdown in coordination
  • There was no plan for blood pressure, anticoagulants, dysphagia
  • There wasn’t really a voice for the family
  • Anticipatory care was not in place
  • There was not enough after care with Jack to pick up on what was going on with Mary. Are we doing enough with after care with patients and their caregivers?
  • Each area of care didn’t know what the other one did
  • It is so easy to lose things between the cracks
  • The continuum of care is a blessing for those who have it
  • Acute hospitals are looking for solutions and we can be that solution
  • Was Mary’s first transition an appropriate transition? Was she ready for SNF care?
  • Were advance directors figured out?
  • Was the PCP overlooked?
  • Goals are not being taken down to the bedside