Skilled Nursing adds an extra dimension to the care of the home health patient. Many elder patients are living with a chronic illness that must be evaluated on a regular basis to ensure that the plan of care maintains the client in a safe environment.
Conditions like CHF, COPD, and diabetes depend upon proper medication and diet. A five pound weight gain for a person with CHF can be a critical sign that must be evaluated. COPD with an increased difficulty in breathing can also be a cause of great concern. Elevated blood sugars in diabetics must be tracked down as to why they are elevated.
Medication compliance in the elderly is also a great concern. The elderly often has multiple doctors, each ordering medication. This adds to the confusion as to which medication to take and what time to take it. This can cause an overdose in medication or death in the case of insulin.
Clients often have a change of condition and it may take weeks to see the family physician. Many people who do not know how to evaluate the condition often wait until the physician’s appointment, and a condition such as a bladder infection could have been treated much sooner. RNs know how to navigate the system and can get a physician’s order and lab work done without waiting for an appointment.
The RNs doing case management work closely with medical and non-medical professionals to meet complex patient needs and collaborate with the interdisciplinary team to maintain the plan of care.
The care coordinator’s job is to recognize changes; treat new problems; maintain communication with the patient, the patient’s family, caregivers, physicians; and to coordinate with other providers and agencies. Our goal is to improve and maintain the life of the client with continuity and quality of life.