VS Voiceover:
My mother Su is 72 year old and lives in Calgary. My dad died 5 years ago and she has been living on her own ever since. All of my brothers and sisters have moved away.
Keep one of the siblings in town to assist Su as she attempts to return to home, likely a daughter.
3 weeks ago Mom had a bad stroke. Her neighbour found her lying in the garden and called 911. My mom is in the hospital now but she can’t speak very well and can’t swallow so the nurses feed her through a tube. She also can’t walk and so they use a mechanical lift to move her to a wheelchair.
My mom, my brothers and I had a meeting with some staff from the hospital and we all agreed that Mom can’t live by herself anymore since she had her stroke and so she will go to a long term care home where there are people who can look after her.
Case study Script Build
What information should be included in the discharge summary?
?Learner lists ideal summary - compares to example - Learner adds omissions, corrections.
What resources are available to help the staff at LTC learn more about how to look after Su
Staff are reporting that she is very motivated?
Can we refer her to inpatient rehab? Yes she is being rehabbed to go home.
How can we do this?
- LTC may not be Su’s final destination, her recovery, is not a one way street.
Q: Acute to LTC What information should be in included discharge summary?
Best practice p44 discharge list ( include rehab status )
QWhat other reports might be of value?
Therapists reports: dietitian, OT and PT
QShould Acute call LTC to smooth Su’s transition ?
Phone as well to confirm
Q: What resources does LTC to learn about Su’s condition?
‘Tackles’ resource Heart and Stroke for Community ( which replaces Tips and Tools)
Arrange Telehealth meeting before transition from acute to LTC
Q Ask your therapist for info for caring for your stroke patient ? A Therapists can provide learning support to LTC staff
After a few weeks at the LTC Su is beginning to swallow and doesn’t need the mechanical lift, transfers with the help of 2 staff
Q: How do we support Su’s transition to a rehab unit where she will receive more intensive therapy? Begin referral from LTC to rehab unit?
Monitor patient for changes, improvement, increase mobility
Referrals for therapy Reassessment
Many programs and services are available for stroke patients across the continuum of care in Alberta. Transitions across those services need to be supported in a timely and effective manner. We hope by working through this transitions module learners can go forward with an increased awareness of tools and processes to support stroke patients and their families in their journey.
CLOSING NOTES
Trudy’s Notes on Summaries & Questions:
Summary for Su:
What happened next?
- Su was accepted to an Inpatient Neuro-Rehab program
- While there, she progressed to a one person transfer, was able to swallow and eat a regular diet, her speech improved slightly and she learned many techniques to help her communicate better
- She was discharged to her daughter's home with some support from Home Care
- She continues to make improvements while participating in a community rehab program
Questions for Su:
communication to LTC (discharge summary, Telehealth, phone call), reassessing, re-entry,
↑↑↑ DONE
TO DO
Summary for Andy:
Andy returned to work
Continues to monitor his blood pressure
Sees family doctor regularly
Questions for Andy:
Signs of Stroke FAST, timing of education, Stroke Prevention Clinic, communication
An easy to remember the signs if stroke is FAST
What does FAST stand for?
Red herring Ask the person can you smell? Ask the person can you stand ?
ANDY
FACE: Ask the person to smile. Does one side of the face droop? | ||
ARMS: Ask the person to raise both arms. Does one arm drift downward? | ||
SPEECH: Ask the person to repeat a simple phrase. Is their speech slurred or strange? | ||
TIME: If you observe any of these signs, call 9-1-1 immediately. |
timing of education
Educate about how to give insulin NA
Talk about access to physio ( as he doesn’t need any won’t apply) NA
FAST,E SPC
TAught about CT scans and other tests,E Importance of follow up Primary care physician and stroke specialist, Risk factors E SPC FD, , Learn about Statins fd, Reinforce information from other healthcare providers relevant to the patient's unique situation.FD SPC Lifestyle : FD + SPC Hypertension SPC FD Aspirin E Community Support SPC FD, TIA education E SPC FD,
Emergency:
Stroke Prevention Clinic
Family Doctor
Not applicable
FD
Importance of follow up Primary care physician and stroke specialist,
Risk factors
Learn about Statins
Reinforce information from other healthcare providers relevant to the patient's unique situation.
Lifestyle
Hypertension
Community Support
TIA
SPC
FAST
Importance of follow up Primary care physician and stroke specialist,
Risk factors
Reinforce information from other healthcare providers relevant to the patient's unique situation.
Lifestyle
Hypertension
Community Support
TIA Education
TIA
Community Support
Aspirin
Hypertension
Lifestyle Changes
Reinforce information from other healthcare providers relevant to the patient's unique situation
Learn about Statins
Stroke Risk Factors
Importance of follow up Primary care physician and stroke specialist
Learn about CT Scans and other diagnostics
Questions for Sylvia:
What services can ESD provide?
Drive patients to and from appts. Red herring
Clean their house RH 2
Physiotherapy in their home
Help reintegration into community
ESD is not available to LTC clients
There is a referral process for ESD
Speech therapist
Occupational therapist
Social workers
Therapy assistants
WHat criteria for esd?
Must be stable mild to moderate deficit and
**** Therapist or nurse or doc must make the ESD referral
Self management
WHat are some examples of documentation for self management
My medical issues
Important phone numbers and contacts
Medication list and diary
primary care physician transition
SESD, primary care physician transition, self management
Some things to think about:
Sylvia
I don't think we explained what SESD is? could link to AHS http://www.albertahealthservices.ca/info/service.aspx?id=1068163 or just explain it can we take out the reference to Drive able in the driving section - there are other programs and we might not want to promote one particular program.
Were we going to use an example of a discharge summary somewhere?
Scripting Assessment
STill trying to knock off my assessment. I have an idea, but the wording is not there yet.
Along the lines of now that you have been thru this training, a newcomer to your clinic needs your support with stroke transitions.
And then you can run thru variations of the previous encounters. MC would work, but scenario based it might remove that crazy multiple choice taste, I hope.
You have been asked to help X who is new assist her stroke patient through her health care transitions.
After going through Su’s Stroke Transition Learning, a
PART 2
Dorothy’s 2 cents
Q1 ‘How do we help our stroke patient transition to LTC ?
Which one of these choices would not
a) Complete a team discharge summary
b) Provide patient and family with resources to help with long term care decisions.
c) Call the LTC facility to provide patient care plan.
d) Insure reports are completed from Dieticians, therapists
Inform the patient that Access to intensive therapy is not possible from LTC.
Which doesn’t belong together together? Drag and Drop . . . .
Q2 ‘ Is there therapy available to LTC patients? How does that occur?
a) LTC facilities have access to therapy
b) if your patient shows great progress based on observations by staff and family a request can be made for more intensive therapy.
c) A Stroke Rehab Referral form is forwarded to the Stroke Rehab
d) There is no access to therapy for stroke patients in Long Term Care ‘
Order or put these in steps . . .
Many people are under the misconception that LTC is a one way street where stroke patients may go but never return.
Q3 ‘How can we assist LTC staff become more familiar with Stroke Care ?
a) The heart and stroke community has many resources, including the ‘TALCS’: Taking Action for Optimal Community and Long-Term Stroke Care: http://www.strokebestpractices.ca/index.php/taking-action-for-optimal-community-and-long-term-stroke-care-a-resource-for-healthcare-providers-tacls/
b) A telehealth meeting between transitioning facilities.
c) The therapists in LTC can not recommend treatment and care options ‘ ( red herring)
Which resources are available to assist ? placebos plausible or funny ?? or rank these resources ---> feedback gives same +ve or negative same, give a few lukewarm resources very broad / Survey says: