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Forming a Caregiver-Clinician Partnership to Address Dementia Concerns

Residential Nurse Alert to the Rescue

When one caregiver recognized signs of dementia, she used Residential Nurse Alert to join forces with her father’s Residential Home Health care team.In a Residential Home Health care team, the ‘team’ aspect is essential. A patient’s nurses and therapists coordinate and share information in order to deliver exceptional, thorough care. Other important partners in a patient’s care are his or her caregivers: while Residential clinicians provide irreplaceable expertise and vital patient care, caregivers are ‘in the know.’ They spend the most time with the patient, they often have years of experience with him or her, and they can contribute to the care team by communicating their own observations about day-to-day developments.

When one caregiver recognized signs of dementia in her father, the Residential Nurse Alert personal emergency response system let her voice these concerns and ask for help, and allowed the patient’s Residential Home Health care team to quickly respond and coordinate. Read on for the story of how their open communication and teamwork resulted in better care together than they might have achieved alone.

Something’s amiss

The patient was under a Residential Home Health plan of care after a recent bout of ill health (e.g. pain, weakness, and diabetes complications) and hospitalization. He was receiving visits at his senior apartment from his Residential care team as well as from his daughter, but he was alone for much of the day. The clinicians had noted that the patient had some cognitive deficits and worked with him to address them whenever they were in the home. When the patient’s daughter came to visit one Saturday, however, she was uniquely situated to recognize that the situation was getting worse: he was having difficulty remembering things he had been told, and could not recall whether he had eaten or taken his medication — both red flags with respect to diabetes management. Moreover, he had also placed items on a hot stove and then forgotten about them, a serious fire hazard.

As his primary caregiver, the patient’s daughter recognized that her loved one’s cognitive deficit could place him in danger while at home alone, and wanted to ask about getting him more hands-on help. Because she was not usually at home for her father’s visits from the Residential Home Health care team, and his condition meant he may not be able to pass along her concerns, she needed to connect with his clinicians directly. So the patient’s daughter pressed his Residential Nurse Alert button — even though it was a Saturday — for immediate contact.

A powerful partnership

In no time after sending the alert, the patient’s daughter was able to voice her concerns about her father’s cognitive deficit, and she also made three requests of the Residential Home Health care team:

  • First, she asked for a nurse to assess her father for possible dementia, as this was not a specific part of his initial diagnosis and plan of care.
  • Second, she asked about options for increased aid and assistance with the patient’s activities of daily living, especially meals.
  • Finally, she requested that the clinicians contact her directly with updates, because her father may not be able to recall what he was told during their visits.

These requests were communicated to the patient’s primary nurse for prompt consideration, and the decision was made to add a medical social worker to the care team. Within a few days, the social worker had conducted an evaluation and identified that the patient was eligible for a state-run Medicare program that offers valuable home support resources, including meal assistance. Immediately after the visit, the medical social worker called the patient’s daughter for discussion, and offered to initiate this Medicare benefit request on the patient’s behalf. The social worker also informed the rest of the care team about these developments and let them know he would follow up for further long-term planning.

A stronger care team

By joining forces, this attentive caregiver and the resourceful Residential Home Health care team were able to communicate clearly and immediately adjust this patient’s plan of care. In response to his evolving needs and home safety concerns, they swiftly added a valuable member to the patient’s Residential care team, a medical social worker who problem-solved to secure the resources needed. Not only did this patient benefit from the comprehensive care of Residential Home Health, but the Anytime-Anywhere-Anything assurance of Residential Nurse Alert made it quick and easy for his daughter to contribute and cooperate as an essential partner in his care.

While this patient’s caregiver used Residential Nurse Alert to request additional help and services, this exclusive mobile alert system can be used for any reason, day or night:

•Emergency situations

•Questions regarding hospital discharge instructions or medications

•Help with scheduling physician appointments

•Assistance with transportation

•Questions for your primary care physician

•Health concerns or any other reason

Residential Nurse Alert provides patients with Anytime-Anywhere-Anything access to their care team. Non-patients can also use the service to connect with Residential’s clinical team. In 2014, more than 300 probable hospital admissions were avoided with this system. For more information, click the link below, or call (866)902-4000 to speak with a nurse.