A hospital’s Care Transitions Clinical Coordinators program provides patients and caregivers with care transition support. The program focuses on assessment and identification of the root cause of readmission, as well as other key interventions.
The frontline caregivers who visit patients’ homes and provide help with their activities of daily living often are the unrecognized helpers, preventing chronically ill patients from heading to the emergency department or hospital. As population health initiatives and case management increasingly transition at-risk patients home and keep them out of the hospital, there is a greater need for home-based resources.
The proportion of Americans with Alzheimer’s disease and related dementias is expected to grow from 1.6% of the U.S. population in 2014 to 3.3% of the population in 2060. Case managers might see patients who have not been diagnosed with dementia forget their medications, or not eating, exercising, or sleeping well. Their family caregivers might say the patient is driving them crazy, but cannot explain any recent behavioral changes.
The COVID-19 pandemic changed routine case management of older patients. Case managers have had to more creative in finding community resources and post-acute referrals for patients since many organizations were closed or limited in their services for months.
For hospitalized COVID-19 patients, surviving the infection is the first major hurdle — but it may not be the last. Their recovery may involve rehabilitation, depending on complications from ventilator-related immobility or damage from blood clots. Rehabilitation facilities have updated their processes to accommodate these patients’ special needs.
COVID-19 has brought new challenges to discharge planning for elderly and seriously ill patients. Long-term care facilities still are accepting patients, but they will be in quarantine the first 14 days. The case manager should consider the patient’s needs before transfer to the facility.
The authors of a review of randomized, controlled trials found that mindfulness-based stress reduction may reduce short-term anxiety and depressive symptoms in people caring for family members with dementia.