1. Moran, Peter MS, BSN, RN, BC, CCM

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I currently work in a busy emergency department (ED) and, from time to time, have had a few "AHA" moments, or insights into situations, which might seem simple and straightforward.


I recently walked into work and was barraged by several staff members about a gentleman I will call Bill. Bill, who was elderly, was brought to the ED the prior evening because his primary caretaker took ill. Bill has had a previous stroke with residual hemiparesis. His primary language was not English and also had some problems with garbled speech. Bill had been in the ED overnight and was awaiting an inpatient bed and case management because there was considerable concern that he would be unsafe to be discharged. In addition, Bill was agitated because he wanted to go home and, as is often the case, the staff wanted the case manager to fix the problem.


The first thing I did was take Bill into a quiet room to decrease the surrounding stimulation and ask him why he was so upset. He was able to clumsily verbalize that he usually takes medications three times a day and he had not gotten them since his arrival. I was able to get his medications ordered. He also was concerned and worried about his wife, who had been hospitalized the night before. I looked in the system and learned that Bill lived in a second-floor apartment with steps, but had been able to stay at home in the past when his wife had been hospitalized.


The good news was that Bill was enrolled in a Medicare Demonstration Project for case management and had a community case manager, J.S., who knew Bill and his wife, as well as the support network that was available to them. I called J.S., who quickly came to see Bill in the ED. She knew that his third-floor neighbors were like family and were willing to watch him and assist them in his home environment. She knew that the son, who lived across the country, had some resources and could afford to private pay for some assistance in the home. J.S. was also familiar with the agency Bill had previously used. These are the "intangibles" that are not easily discoverable, because the medical record frequently lists only the spouse as "next of kin."


Bill's face lit up when he saw her because he knew he had someone who would help him. J.S. arranged for him to be discharged from the ED. She brought him upstairs to visit his wife, and then she took him to his primary care physician so that he could get an influenza shot. Then, next stop was to her office where she got him a cup of coffee and wait for someone to come take him home.


It struck me that many people have community case managers, whether through agencies for aging, insurance case managers, practice-based case managers, Child and Family Services, or even through private pay case managers. However, many of us focus only on the immediate needs. I see incapacitated, ill members being brought to the ED because their caretaker has taken ill. The question in my mind is: Are we discussing in precrisis stage what the plan would be if the caretaker got sick? Have we identified a family member or friend who would be able to step in and assist? Have we explored whether the client would be safe at home, or whether short-term placement would be required? Have we explored resources and how they would be covered? Have we documented a plan that is accessible to other case managers?


I know that we all struggle with heavy caseloads, but in terms of quality transitions of care and the best interest of the client, these things are best discussed early and before we reach a crisis situation. The ED should not be the "easy way out." If the ED case manager knows what the plan is, we could easily work on it. Usually, I spend most of my day trying to figure out what supports and resources people have available, but many times patients end up admitted as "social admits," because the information is not readily available. I now call and ask community case managers what the plan was if the primary caretaker takes ill. I hope this raises awareness of the issue and we will all be more cognizant of incorporating the plan into practice. As I age, I can only hope to have a true case manager, an advocate, and one who focuses on a holistic plan of care, like J.S., as my unsung heroine.