Jack and Mary: Care Transition Fiction

By Lauren Williams

fpcis1Throughout the seventh annual Kindred Clinical Impact Symposium, Kindred's clinical leaders have come back to the fictional case study of Jack and Mary Marton, a couple in their late seventies facing a bevy of medical conditions and issues as they struggle to remain independent. The Martons and their health issues have played a role in Clinical Impact Symposiums past, as well, and their example is useful in helping participants brainstorm and learn about how to better handle some of the common problems patients like the Martons face.

This year, the Martons are still contending with the effects of Jack's bicycle accident years ago, after which he underwent rehabilitation at several Kindred settings. He was independent in all of his activities of daily living, and used a cane while walking outside the home. A year after Jack's accident, Mary suffered an ischemic stroke and while her physical function remained largely intact, the episode left her with mild dementia and mild depression. She required assistance with her medications, cooking and getting around the community and Jack was her primary caregiver. Until…  

Fatigue, dizziness, constipation and dry mouth begin to plague Jack. He became scared of falling. He often forgot to use his cane. And the Martons home had many hazards including throw rugs on hardwood floors and no railing on a steep step leading to the garage.  

While running late for an appointment with Mary's neurologist, Mary becomes pale and nauseous and as Jack turns quickly to assist her, he falls to the ground and breaks his hip.  

Surgery was performed and Jack was later transferred to a Kindred Inpatient Rehabilitation Facility. His progress was limited due to his inability to put weight on his left leg per his surgeon's orders. Meanwhile, at home, Mary was not doing well without Jack. The Martons' daughter, Allison, decides she must take a leave of absence from her job, leave her children with her husband and come to town to take care of her parents. Allison is seething because she has a brother who has gone radio silent in the face of the family's challenges. While Allison makes arrangements, she contacts Kindred at Home Community Care after a conversation with a registered nurse at 1.866.KINDRED.  

jackandmary2Armed with this information about the Martons, symposium participants broke into small groups made up of representatives from the disciplines of physical therapy, occupational therapy and nursing. One session focused on falls management specifically. The groups went through Jack and Mary's fall risk factors and which were modifiable; what screening tests they felt were needed for the two; what referrals were needed and what assessment measures might be used. New or worsening risk factors were also discussed. Community resources, such as Meals on Wheels, were also considered. Finally, the groups came up with intervention approaches and anticipated barriers.

Small group discussions allow the participants - who represent Kindred facilities all over the country - to discuss common challenges in the context of the fictional case study of the Martons. Participants shared anecdotes from their own practices, talked about regional differences and brainstormed solutions to some of the fictional Jack and Mary's very real problems.