MSN6610 – Case Coordination Scenario

MSN6610 – Case Coordination Scenario

MSN6610 – Case Coordination Scenario

Activity Log

Patient Interview

Rebecca Snyder

Patient

How are you feeling today, Mrs. Snyder?

Oy, I’ve been better, I guess! The pain medication is making me very sleepy. But it’s controlling the pain. So I guess I can stand it for now. But when I go home I’m not going to be able to be this out of it. Mostly I’m just worried sick about my family. I’m the one who takes care of everything. And I mean everything–the cooking, the cleaning, the dogs, rides to baseball practice for my sons… and my mother too. She lives with us, and I take care of her because she’s not well. I just want to go home so I can take care of everything like I’m supposed to!

Can you tell me about your family situation?

Well, David is my husband. We’ve been married for 36 years now! He used to be an accountant, but last year he finally took the plunge and bought his own deli. His dream come true. It’s going ok, but it’s a lot of work, and sometimes I don’t see him all day because he’s working. And we have five children. Two of them are at home–my twin boys Eli and Isaac. They’re 14 and they’re really great kids… they’re both on the baseball team and all kinds of activities, and I feel like I spend half my life driving them places. And also taking care of their dogs… oy. We never had dogs before, but the twins just begged us for years, so we got them two great big Golden Retrievers. The deal was that they were supposed to take care of the dogs, but you can imagine how that went!

Then we have three grown kids. Our oldest son Oren lives in New Jersey and we don’t see him enough. He’s married and has four children. Our daughter Devorah lives close by and I see her every day. She has two beautiful little girls and she’s a little overwhelmed, so I help her out as much as I can. And our other son, Avi… oy, he’s a handful! He has a little boy and just split up from his lovely wife, which I keep telling him is a terrible idea, but why would he listen to his mother? My husband made him the assistant manager of the deli, and that’s been an absolute disaster–especially because, well, I hope I’m not telling you too much, but he has a drinking problem. That boy needs to learn some responsibility fast. The other member of my household is my mother, who’s 87 years old and not in good health. She was doing fine on her own until a few years ago, but now the dementia is getting worse and she just can’t be alone anymore.

Is there someone at home who can help take care of you?

Take care of me? Now that would be a change. I mean, I don’t want to complain.

We’re a very traditional family when it comes to women’s work and men’s work.

And that was completely my choice. I actually wasn’t raised Orthodox. My family was somewhat observant, but not the way we are–we didn’t keep kosher growing up, and my mother worked as soon as we were in elementary school. I met David at a dance, and that was that. I married him and became Orthodox. So I chose this lifestyle and the traditional gender roles that come with it. I couldn’t imagine it any other way. So no, there’s no one who can take care of me, not really. David, he’s a good man and he’ll do what he can, but he’s been working 15-hour days lately! I’m sure my daughter can help me with medication and things like that, but she’s so busy with her kids that I don’t want to burden her. We do have neighbors and friends from our synagogue…I’m sure they’ll be sending us meals and looking in on me, just like I’ve done for lots of other people over the years.

How is your home set up? Do you have to walk up and down stairs often?

Outside, it’s not a problem. There’s only one step up into the house. But we do have a lot of stairs inside. David and I used to sleep in the first floor bedroom suite.

But then when my mother moved in, we moved into a bedroom upstairs. She uses a walker and there’s no way we could move her into any other bedroom.

MSN6610 – Case Coordination Scenario

How are things going with your diabetes?

I know… I really need to control my diabetes better. I put on all this weight when I had the twins and I’ve been gaining and losing the same 15 pounds for years, but I just can’t seem to get it off. I run around so much, you’d think that would help… I mean, I walk those dogs twice a day most of the time! But it’s just so hard to eat right… and I know, I use food as a crutch when I get stressed out about my son Avi and stuff like that, which happens pretty much all the time! And I know it would be good for all of us to make changes in our diet, but that’s not easy. My husband is the pickiest eater and my mother can only eat certain things, and three of my kids are lactose intolerant, and now it turns out my baby granddaughter who’s at my house every day has a nut allergy! And on top of all that I need to maintain a strict kosher household. There’s too many food requirements already for me to add my diabetes to the list.

MSN6610 – Case Coordination Scenario

How do you feel about chemo and radiation?

I don’t know. To be honest, I’m worried sick about the pain and the nausea. I’m terrible with pain! With all my kids, I wasn’t going to have an epidural, but every single time I wimped out pretty much immediately. I kind of wonder if I should go back on anti-anxiety pills, because I’m really upset about this… but I’m worried those will make me really sleepy, which is why I stopped taking them.

But the thing is, my doctor says the chemo and radiation could prolong my life by a couple of years potentially. Maybe even more. I know a number of people who were supposed to die of cancer right away and they hung on for years! So that’s what I need to do, right? (tears up) My family needs me. I’m honestly more scared about what’s going to happen to my family when I’m gone. God will take care of me, but who’s going to walk the dogs?

MSN6610 – Case Coordination Scenario

What questions do you have for me?

I’m so worried about my mother. Can you… I don’t know if it’s part of what you do, but can you help me figure out what to do about her? I was determined to keep her out of a home no matter what, and I still feel that way. But what if I can’t take care of her anymore? My sister lives in Florida and I guess she could take her in, but I don’t want to send my mother so far away when we’re her main support system…and anyway, I frankly don’t think my sister has the patience to handle my mother’s health problems. It’s probably too much to ask, but if you could give me some advice about what to do for her…? This is really eating me up inside.

Family Interviews

David Snyder

Rebecca Synder’s Husband

Mr. Snyder, I have some questions for you about your wife’s care.

DAVID: So you’re from the hospital? Is my wife okay? Oh good. MITCH! NO, PUT THAT DOWN! I’LL FINISH THAT ORDER! Okay. I’m sorry about that. I’m at my deli. Things are kind of crazy here today. MITCH! I SAID, I’LL FINISH THAT ORDER! GO WORK ON A DIFFERENT ORDER! I’m really sorry. You said you had some questions about my wife? Look, maybe you should call my daughter Devorah. I don’t know the first thing about taking care of someone with cancer. I can’t even tell you how overwhelmed I feel. If I had any idea she was going to get sick, I wouldn’t have opened this deli, that’s for sure. But it’s too late now… MITCH!

MSN6610 – Case Coordination Scenario

PUT THAT VERKAKTE SANDWICH DOWN! I SAID I’LL FINISH THE ORDER!

Look, like I said, I’m not good with this kind of thing and I’m completely overwhelmed. I don’t have any idea how we’re going to manage this. I’ll try to help though. What do you need to know?

DENISE: I’m going to stop you right there. Clearly Mr. Snyder is distracted right now. You might want to talk with him later. But it also sounds like he’s really overwhelmed, and from what Mrs. Snyder said, he might not be the best person to talk to for insight about her care. Caregiving simply hasn’t been his role in the relationship. I recommend you call someone else.

Devorah Kaufman

Rebecca Synder’s Daughter

What’s wrong?

I’m going to stop you right there. You can’t call Mrs. Snyder’s daughter. Refer back to Rebecca Snyder’s electronic medical record. There’s a list of people she’s given the hospital permission to speak with about her care. And there’s only two people on that list–her husband David and her son Avi. I know–based on what you know so far, that doesn’t make sense. Mrs. Snyder said that she was very close to her daughter. When she wakes up, you might want to ask her if she’d like to update the list so that you can talk to Devorah. In the meantime, you’ll have to talk to someone else.

Avi Snyder

Rebecca Synder’s Son

MSN6610 – Case Coordination Scenario

Mr. Snyder, I have some questions for you about your mother’s care.

Oh, I’m so glad you called! My father’s way too upset to talk about this right now, and frankly he doesn’t know the first thing about what my mom needs. My mother probably gave you this big spiel about what a no-goodnick son I am, didn’t she?

Oh, never mind that. I know a lot more about what’s going on than my mother gives me credit. What questions do you have for me?

How is your mother feeling about her illness?

Well, you can imagine, she’s certainly not happy about it! For one thing, she’s worried sick about everyone else. She really does take care of everything in our family, and she likes it that way. On top of everything she does, she insists on taking care of my grandmother and keeping her out of a home. But she’s probably told you all of that. What she probably hasn’t told you is how scared she is about the chemo and the pain. I don’t think she’s particularly scared about death–I mean, more than any of us are–but she’s always been terrified of doctors and pain. I suspect she has a lower threshold for pain than most people. I know I do, and maybe that’s a genetic thing? Anyways, one thing my mom might not have told you is that she’s been off and on anti-anxiety meds for years, and unfortunately they make her really tired so she hasn’t been able to stay on them. And pain is one of her biggest fears. So I hope you and the doctors keep this in mind when you’re putting together a plan for her. She’s not going to tell you how anxious she is about her treatment, but believe me, she is.

Is there anyone in the family who can help care for her?

Yeah…me! She’ll kick and scream because she thinks that’s a daughter’s role and that I’m a no-goodnik. But my sister isn’t in a position to help all that much. I mean, she’ll do what she can, but… well, okay, please don’t tell my mom this yet, but my sister thinks she might be pregnant again. So she’s already got two little girls under the age of four and possibly another one on the way, and she doesn’t seem to have easy pregnancies. So if she’s actually pregnant, she’s not going to be able to help all that much, and even if she’s not pregnant, she’s already overwhelmed with parenthood. But I can help. And my little brothers can help out too. She’s always complaining that they don’t do things like walk the dogs, but that’s because she doesn’t make them. They’re 14 years old and they’re perfectly capable of cleaning up after themselves and doing some of the cooking. Also, I’m sure my mother hasn’t said anything, but she has a sister who lives in Florida who will be more than willing to fly in and help. She and my Aunt Janet don’t get along all the time and I’m sure my mom doesn’t want to burden her, but Aunt Janet is retired and has plenty of money and would be on a plane in a minute if my mom would ask.

MSN6610 – Case Coordination

Can you describe the situation with your grandmother living in the home?

My Baubie needs to be in a nursing home. In my opinion, that should have happened six months ago, even before my mom’s cancer diagnosis. I admire my mother for taking on the role of caregiver, but there’s a point where it’s too much.

When my grandmother started needing help bathing and feeding herself, that’s when she needed to move out, in my opinion. Also, my grandmother’s wandered out the front door by herself a few times. She hasn’t gone far and she hasn’t gotten lost, but I think there’s a good possibility that could happen.

How would your mother feel about a home health aide?

Oy! She’d kick and scream and tell us she can do it all herself. But she’d probably go for it eventually. The problem with that is that I don’t know if they could afford for someone to come in. When my dad was an accountant they had better insurance.

But now that my dad quit and started his own deli, they’re covered by insurance through the Affordable Care Act. And thank God that’s available! But I don’t think it covers home health care, does it? That’s something we need help figuring out.

Because the deli has been a huge financial burden for the family. Huge! It’s doing pretty well, but all businesses are slow at first, and there’s just not that much money coming in. And my mom has been adamant about not tapping into my brothers’ college funds for her health care. Ugh! I really don’t know what we’re going to do. I wish my mom were old enough for Medicare, but she’s only 56.

Do you think your mother would be open to help with her diabetes and nutrition?

Good luck with that! My sister and I have been on her case for years to start eating better and she won’t listen to us. And my father is absolutely no help. He’s the pickiest eater I know and goes nuts when my mother tries to make something more healthy. He insists that she make pies and cookies even though my mom has no willpower around those things, so they’re always in the house. And now that she has cancer, I know that a healthier diet would make things a little easier for her, but I just don’t see that happening. I see my mom just throwing in the towel and saying that she’s dying anyway and she should be able to eat whatever she wants.

MSN6610 – Case Coordination Scenario

Is there anything else you’d like us to know about your mother’s care?

My father is having a really hard time coping with this. He’s coping by working more, which is pretty much the opposite of what should be happening. My father is completely ill-equipped to deal with this situation, both emotionally and in terms of knowing how to be a caregiver. I wonder if there’s some kind of Jewish support group we could find for him. And no one wants to talk about this, but there’s a pretty good chance he’s going to be a single father to my little brothers. I think my mother thinks that Devorah’s going to raise them, but I don’t think she can handle that, especially if it turns out she’s pregnant again. Our family needs to have a serious conversation about that, but we’re not so great at communication.

Case Strategy Meeting

MSN6610 – Case Coordination Scenario

Panel participants

Karen Wu

Dietician

Samantha Rockwell

Social Worker

Nora Jackson-Green

Case Manager

Panel Q & A

Do you think a home health care nurse is a viable solution?

Karen: I think that’s the best solution. It definitely sounds like Mrs. Snyder doesn’t have anyone who can take care of her to the degree to she needs. She needs to have a home health nurse working with her on her diabetes and to assess her for additional problems.

MSN6610 – Case Coordination Scenario

Samantha: That may be the case. But it sounds like they have financial concerns.

Nora: They have insurance under the Affordable Care Act. If home health care turns out to be the best option, you’re going to need to do some research and find something that’s covered by the family’s insurance.

Karen: I know finances are a concern. But if there’s any way to make it work, this sounds like a clear-cut case where a home health care nurse is needed on a part-time basis. The fact that she’s done such a poor job taking care of her diabetes is evidence that she’s not going to be able to care for herself on her own.

It sounds like there may be some relatives who are able to help. To what degree should we pursue that?

Nora: According to Mrs. Snyder’s son, she has a sister in Florida who may be able to help.

Karen: But it sounds like Mrs. Snyder is reluctant to ask her sister for help.

Samantha: I agree that this sounds like a good potential option. Maybe you could discuss this more with Avi? You might suggest that he give the sister a call.

Nora: And you probably should talk more with Avi about getting family members to pitch in.

Samantha: Are you sure? It sounds like Mrs. Snyder isn’t on the best of terms with Avi.

Maybe we should try to communicate again with her husband.

Nora: Maybe. But so far her husband has been very uncommunicative and seems to be in denial. Avi was very helpful on the phone. It’s possible her relationship with her son is better than what she says it is.

Samantha: Regardless of who we talk to, I think we need to find some resources to help the family out. This isn’t the first family with this problem. I recommend you contact Jewish family resources in the Minneapolis area and find out what resources they have available to help with this family.

Nora: That’s a very good idea, Samantha. And find out about possible resources through their synagogue. The family seems to be strongly affiliated with the Orthodox Jewish community in the area. It’s likely that there are informal support systems that can help the family with things like meals and housekeeping.

What should be done about Mrs. Snyder’s mother?

Nora: I think this has to be a priority. Mrs. Snyder is her primary caregiver, and that’s not sustainable anymore.

Karen: I agree. Mrs. Snyder needs to be able to focus on her own health care needs, including diabetes care and nutrition.

Nora: There’s also the matter of the first floor room where her mother stays. Mrs. Snyder is overweight and not in good shape. Once she’s exhausted from the chemo, those stairs are going to be a real burden.

Samantha: But she’s quite adamant about her mother staying. We can’t make her get rid of her mother.

Karen: No, but the case manager can strongly recommend this. And we can try to get other family members on board. Avi certainly agrees that it’s time for the mother to live in a facility.

Nora: If this is going to happen, we need to find a facility that the family can afford and that Mrs. Snyder feels comfortable with. And it needs to be reasonably close to their home.

Samantha: And it needs to cater to Jewish families.

How should we address the issue of Mrs. Snyder’s anxiety, especially in relation to pain?

Samantha: I’m so glad you’re addressing this. I’m afraid that medical providers sometimes dismiss anxious patients as problem patients.

Nora: I agree. One thing we can do is educate Mrs. Snyder about pain relief options. She needs to know that if something isn’t working, there are other drugs and other options.

Samantha: I also think she would benefit quite a bit from talking to a counselor about anxiety. Especially since she hasn’t had success with anti-anxiety drugs. Or maybe she would benefit from a support group.

Nora: Keep in mind that she has financial concerns. But I definitely agree that counseling of some sort would help her.

MSN6610 – Case Coordination Scenario

Karen: I also think it would be helpful to talk with her about nutrition in relation to anxiety.

Obviously that’s not the only answer. But she might be able to address the anxiety in part through dietary changes–and through exercise as well.

What can we do to help Mrs. Snyder with diabetes and nutrition issues?

Karen: This is so important. Improving her diet and getting the diabetes under control will make her feel better. Good nutrition can help a patient feel much stronger during cancer treatment. She needs to be eating foods that are easy to digest and that are high in protein. Many cancer patients need to drink supplemental shakes to make sure they get the nutrients they need. And it may not be realistic to get her down to an ideal weight, but a moderate amount of weight loss may help her feel better and make it easier to control the diabetes.

Samantha: I think we should try to get the family on board to help. It sounds like she’s meeting resistance from her husband when she tries to cook better. That’s hard to get around in such a traditional family.

Karen: I’m wondering if it’s possible to get a dietician to come to the Snyder’s home and work with the family.

Nora: Maybe. But don’t forget that they have financial concerns.

Karen: At the very least, we need to make sure she talks to a diabetes educator before she leaves the hospital.

How can we help the Snyder family adapt to this situation and to the possible loss of Mrs. Snyder?

Samantha: We really need to identify some resources for the family.

Nora: It sounds like they need help communicating with each other. Mr. Snyder sounds like he’s in denial. Nobody’s talking about things like finding a facility for the grandmother.

Or what’s going to happen to the two teenage boys if their mother passes away.

Samantha: I hear you. They have so many needs that I’m not sure where to start. I guess the first thing to do would be to find out what resources are available in the Jewish community.

Nora: Cancer support groups for the husband and the kids would be a big help too. I know there are support groups available for teenagers who have parents with serious illnesses.

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