Nursing

Managing complex cases

Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 17, 2005

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A husband and wife, 92 and 89 respectively, come to the emergency department (ED) one evening. The husband is in good health, and the wife has mild dementia with periods of clearing. Both patients ambulate well without assistance. The elderly couple lives with one of their daughters who acts as the primary caregiver. The couple's son brought them to the ED. The son has requested custodial placement from Elder Protective Services, saying his sister abused his parents. He is also seeking a court order to remove their parents from his sister's home. The son has contacted a lawyer who is directing his actions. By bringing his parents to the ED, the son hopes a physician will admit them for a three-night stay so Medicare will cover placement in a nursing home. A psychiatrist assesses the couple in the ED and states that there are no active psychiatric issues at that time.

The case manager's approach:

The case manager is called to the ED to determine whether the couple needs hospital-level care, and whether a three-night stay is justified. She is aware that the ED is almost full and that the in-house hospital beds are limited. The case manager observes that the husband and wife appear completely devoted to each other. They both tell her they don't want to be separated, which the case manager knows is a possibility if they go to a nursing home. They also tell the case manager they want to return to their daughter/caregiver's home.

After the assessment, the case manager concludes that she cannot justify a three-night hospital stay for the couple. However, she can't legally send the couple home because of the pending court order against the daughter/caregiver.

A temporary solution:

Taking a risk, the case manager calls her director and asks for approval to let the couple stay in the ED overnight. This seems like the only choice because the couple cannot be sent home, they do not meet the hospital-level of care, and a nursing home is not an option at this time.

Editor's note: The above excerpt is from the new online course, "Nursing CE Series: Managing complex cases." For more information on this and other courses for nursing credit in our Nursing library, go to www.hcprofessor.com and click on Nursing CE Series.



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