Transitional Planning for a Case Manager

Because of MRS. S condition and previous medical history it is important to provide her with high-quality transitional care. She is an elderly woman whos suffering from several conditions and this calls for the presence of a caregiver. However, because Mrs S does not have children or other close relatives and friends who could take care of her, it is highly inappropriate to release without confirming and having discussions with the caregiver. So it is important to find a caregiver for Mrs S before discharging in spite of her readiness to leave. Mrs. S is not a good candidate for discharge to home. She is suffering from other conditions that need to be frequently monitored. A home setting is what she wants, but it is not what she needs. The most appropriate care setting for her would be a nursing home care setting.

The case manager will require test tracking and follow-up on Mrs S to ensure her condition does not deteriorate. It also requires for referral tracking and follows up which improves accountability to Mrs. S condition. The case manager will also need to build a patient-centered co-ordination with the care transitions on ensuring Mrs. S routine remains the one that she followed in the hospital especially in terms of her medications. The coordination will need to be with the caregiver and the medical professionals whom Mrs. S is assigned to (Powell, 2010).

The case manager needs to ensure that Mrs. S is capable of performing cleaning duties. She also needs to be capable of cooking because she lives alone. It should be observed if she is capable of performing other leisure activities. These are functional issues that are important to every human being and failure to accomplish one of them could advisedly affect Mrs. S health.

It is important for the case manager to review Mrs. S social support system which is next to none. She has no social support system, and this has contributed to the second psychosocial issue that is depression. Mrs. S is socially isolated, which increases the risk of her suffering from depression. It is therefore important for the case manager to enlist her to therapy. The last psychosocial issue is the cognitive difficulties. Mrs. S lower back pain has undoubtedly affected her ability to perform other cognitive duties that will make her struggle to fit in the social scene.

The first action that could be taken by the care manager is to find Mrs. S a good care setting to be discharged to. The care manager could alternatively find a way of assigning her a nurse to who would visit her on a daily basis to ensure she keeps up on her medication. Secondly, the care manager could decide to find a social support group for Mrs. S by enlisting her to the hospitals own self-help groups. This would provide Mrs. S with a social circle that she lacks in her life. Thirdly the case manager could liaise with the doctors to have Mrs. S come in regularly for medical injections rather than have her take-home medications which she could otherwise forget to take. If she is to take home any medication, it should be those that cannot be administered through any other means.

References

Powell, S. K., & Tahan, H. A. (2010). Case Management: A Practical Guide for Education and Practice (3rd ed.). Philadelphia: Wolters Kluwer Health.