Case Management of Frail - Elderly Stroke Survivors

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The process of case management (CM) is an essential component of quality healthcare. The Case Management Society of America defines case management as follows: "Case management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individuals health needs through communication and available resources to promote quality cost-effective outcomes." (Case Management Society of America, 1995, p.8) "Case management is an intervention strategy used by health care providers and systems to advocate for clients, coordinate healthcare delivery, and facilitate outcomes of both cost and quality." (Huber, 2006). Zander best describes the process of case management as "the nursing process applied at a systems level" (Zander, 2002, p.58).

The CM process, which is often referred to as clinical resource management is addressed in the CMSA's Standards of Practice for Case Management (2002). This provides a guideline for case management and consists of assessment, planning, facilitation, and advocacy; all of which are core functions of the clinical case manager.

This case management plan is focused towards frail, elderly clients who have suffered a stroke and will be returning home upon release from their hospitalization, having care provided to them primarily by a family member.

You often hear the word acute when physicians refer to a stroke, this implies that the stroke is a short-term condition when in actuality; the implications of a stroke are long term and become chronic (Young, 2001). When a stroke is treated as just an acute condition, the clinical outcomes are not as great as if an evidence based model similar to that of a rehabilitation unit is implemented upon returning home from the initial admission (BMJ 1997).

The fastest growing segment of our population is the frail elderly, aged 85 and older (Hobbs 2001). As Clinical Nurse Leaders, it is imperative that we embrace the needs of this rising population and develop plans of care to best suite their ever growing needs; ones that address their quality of life.

Stroke survivors have residual neurological impairments, which require long-term support and care. "Stroke is the leading cause of long-term disability in the US with over one million Americans currently living with serious functional limitations. According to the National Institutes of Health, of individuals with stroke over the age of 65, approximately 50 percent will have persistent hemi paresis, 30% cannot walk without assistance, 19% have aphasia, 35% have depressive symptoms, and 26% require institutional care" (Brashers, 2007). Anxiety, depression and poor physical health are common effects among family caregivers of stroke survivors. There is also an association between the stroke survivor's level of disability and emotional state and the emotional distress of their caregivers (Bugge, 1999).

The American Heart Association (2005) identified family cooperation as an indicator for successful rehabilitation after a stroke. However, many family members take on the responsibilities of care giving in addition to their routine activities and work schedules. Primary caregivers who work must rely on other family members to assist with care giving responsibilities. The amount of care provided by a single caregiver can be reduced if responsibilities are shared; sharing the responsibilities requires that family members collaborate and communicate. Studies have shown that family relationships deteriorate after a member survives a stroke (Anderson, Linto, & Stewart-Wynne, 1995; King et al., 2002), and ineffective family functioning (families not communicating and problem solving well) has been associated with negative psychological outcomes for caregivers (Clark et al., 2004; Evans, Bishop, & Ousley, 1992). Model

The Carondelet St. Mary's Community Nursing Network (Arizona) Model is a

hospital to community approach, across –the-...
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