Ben, a previously active senior, entered the hospital in lung failure. He was in the intensive care unit (ICU) on a ventilator for 4 weeks. During his 9 week hospital stay, he lost 60 pounds, he could not drink fluids without choking, and he could not stand unassisted. Ben had fallen through the cracks.
Who was the doctor most responsible for Ben's management? What was the care team's focus? How much did the team know about Ben's changing problems? How much did Ben know about his issues?
With doctors on duty for only one week out of a seven week rotation, they lost touch with the details of the case. There was poor co-ordination and continuity of care.
Once Rupert Case Management (RCM) was retained, our job was to "ring the bell".
Here is what happened. RCM brought awareness of Ben's core issues and critical decisions to all members of the treating team (doctors, nurses, physios and OTs) on a daily basis. This is very important.
Our nurse case managers were tenacious in discovering the core issues, and persistent in communicating these core issues and critical decisions to the treating team each day.
In fact, we have designed a matrix to communicate this information visually. To get the care team's attention, we know that we have to communicate to their visual cortex and engage them emotionally. This was necessary to get the right actions initiated for Ben.
By improving continuity of care and co-ordination of all the different care disciplines, Ben got the attention that he needed. Ben started to gain weight. He ate more. He drank his thickened fluids. He walked with assistance. He perked up and in fact, he got married while still in the hospital. We sent flowers.