1. Treiger, Teresa M. RN-BC, MA, CHCQM-CM/TOC, CCM

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I witnessed an upsetting chain of events while on vacation with my spouse. To set this story up, one should note that my husband and I recently resumed traveling (mostly cruising) after his stroke in 2014. We purchased a collapsible scooter to help him get around the ship on rough seas and to make some of the ports a bit easier. In all honesty, more often than not, he walks around the ship using a quad cane and enjoying his independence.


A big part of cruising revolves around taking excursions upon reaching port cities. In this regard, we apply a measured approach as to our activity. If either of us is not up to it, we simply cancel a tour rather than grit our teeth and soldier on through it. We do not prod each other into overdoing something. This works well for us because we exercise good judgment and respect our physical tolerances. But on this particular occasion, we witnessed two gentlemen as they joined one of our excursions. Even to the untrained eye, one should have been in a hospital or skilled nursing facility. We all saw how much he struggled and more than a handful of fellow passengers were distressed with what was going on. However, his traveling companion (be him friend or relative) appeared to be oblivious to the situation and continued to push him ... literally.


He pushed him up the stairs of the bus, pushed him into the seat (which was directly behind us), and pushed him out of the bus once we arrived at our destination. We could hear him muttering, "come on, do it" or "just keep going," clear enough to those in the immediate vicinity to hear. As the older man passed our seat, a number of us saw that he was incontinent, his blue jeans wet, and his zipper was left down. Another gentleman traveler pointed this out to the companion, who only responded with "yeah, it's a bit too late for that." It was not a matter of misunderstanding what had been pointed out; he spoke clear, unaccented English. It broke my heart that the man just did not appear to be mindful of his companion's physical state, nor that his dignity was suffering a massive blow ... even if he may have been too confused to realize it.


Once seated in the row behind us, the older man's labored breathing, congested cough, and incontinence were enough for me to alert the tour guide of my concern. She made an inquiry before departing the terminal, but the companion insisted he was doing the right thing because he was told to encourage him to get out and keep active.


So what does this have to do with case management?


Granted, I was not privy to any of the clinical facts regarding the man's health, nor the context in which the instructions were given. Basically, it is impossible to know what was said or not said, but in the back of my mind I could hear the voice of a well-meaning health care professional dispensing a generalized recommendation of increasing physical activity at an office visit or as part of transition plan instructions. Case managers participate in countless team meetings to discuss client status and progress. We espouse the importance of caregiver involvement in recovery from illness. We urge caregivers to allow their loved ones time and space to make their own efforts and to praise attempts to regain self-sufficiency. However, are we being clear enough and is that lack of clarity increasing the risk of unintentional abuse and/or neglect by caregivers?


In this instance, it occurred to me that the companion may have misinterpreted what we consider to be fairly common instructions. How often do we reassure caregiver anxiety as to what they should and should not do for the recovering patient? Additional study into what we think we are telling our clients, versus what they are hearing, may prove quite illuminating and serve as a gateway to meaningful change in our approach of how we teach and coach. Does it mean we need to change our entire approach to providing care instructions? No, but we probably need to make a few adjustments.


So, the next time you are care planning or explaining discharge instructions with a caregiver and client, consider the following:


* Assess. Ask a few questions as to what are the usual activities in which the individual participates and if there are any upcoming events such as travel, which might be out of the ordinary.


* Provide context. When providing instructions, place them into contexts that the client and caregiver understand. For example, if the client normally climbs down a flight of stairs to get to the mailbox, make sure the physical therapist weighs in on whether this is something the person should resume doing straightaway. In the case of international travel, this requires a bit more discussion with the care team, treating provider, family, etc. Travel plans can be postponed. In this case, a letter from the provider could help in getting a postponement on the trip and perhaps a full refund.


* Verify understanding. Be sure to apply "teach back" methodology to ascertain whether the receiver of your message understands your meaning. If you do not verify understanding, you may as well have not bothered to provide any instructions.


As with any situation, there are exceptions. In spite of our best efforts, we cannot force our will upon others; people will do whatever they want to do. I do not know what became of the gentleman, nor his traveling companion, but I certainly hope that they both made it back home safely.


The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles.


Mindy Owen at: mailto:[email protected]


Teri Treiger at: mailto:[email protected]