Sarah A. Blakemore, M.S.W., L.M.S.W.; Patti-Jo Dixon, R.N., ACM; Stacey E. Hunter, R.N., ACM; and Laura (Diane) D. Kittle, M.S.N., R.N., discuss how to meet the psychosocial needs of patients and families affected by COVID-19 amidst the additional challenges of obtaining resources.
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Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. Covic, 19 Expert Insights and Strategies is a comprehensive curriculum from the Mayo Clinic for healthcare personnel worldwide. This presentation covers transitions of care for the covert patient evolution of care coordination in a pandemic and is accredited by the A N C. C for 0.5 contact hours. It's important to note that there are no relevant disclosures for all those involved in this presentation. Our panel of experts for this presentation include Sarah Blakemore, Ah, licensed master social worker with Mayo Clinic, who is part of the Critical Care Cove. It cohort. Patty Joe Dixon, registered nurse and accredited case manager with Mayo Clinic, who was part of the Med Surge. Covad cohort Stacy Hunter, a registered nurse accredited case manager and an R N case management liaison with Mayo Clinic. And Diane Kittel, who is an RN certified case manager and operates as a manager for RN case managers within Mayo Clinic. Diane, would you like to get started? Thank you for joining us today for this course are learning. Objectives today are to identify differences in transition planning based upon the patient security critical care versus a med surge level of care address the psycho social impact of the pandemic, the isolation of patient and family impact of socioeconomic factors in determining a safe transition plan. The heightened anxiety from patients and caregivers related to post acute care and then summarize how to effectively utilize and access post acute resource is for co vid positive patients Sarah and Patty Jo How to Critical Care and Met Serge differ in meeting the psychosocial needs of our patients and families. Psychosocial needs. One of the biggest challenges is the isolation. Patients are no longer allowed visitors, and without the support of family friends, patients can become frustrated, depressed, lonely and anxious. If they come in with mild dementia, they can become more confused and restless as time goes on. The health care team is tasked to provide increased emotional support for patient and families to help calm fears and provide frequent updates. Communication has become mawr labor intensive due to the no visitor policy. There's an increased importance for reaching out to families more often, which is time consuming but very important. No more face to face communication. The intimate connection with patients and families that once occurred, um, has gone away. And there's a loss of connection with family on patients. Patients and families often express fear, returning home due to infect and family members that have not tested positive for Cove it families air concerned about how they're going to care for they're ill loved ones. Increased education is a huge part of, uh, health care providers and is crucial so that families can feel a safe. It's possible when reuniting with their families and then also the when loved ones are transferred out of state or miles away from their home for higher level of care. This adds another layer of anxiety and concern for families, even though no visitor policy is in effect. For families living locally or far, being far from home physically takes a toll on them. The patients are eager to get closer to home. Family members want them closer to home, and Sarah, do you have anything to add? The psychosocial concerns we're seeing in our communities and nation as a whole are magnified when facing a medical emergency within a patient supportive nucleus. As the critical care social worker, I'm seeing most frequently patients and families in prolonged stages of crisis. For example, inability to visit worsens the situation as a whole, and patients who are too sick or unable to communicate have to rely solely on staff to keep family informed. Over the course of a patient's hospitalization, we are continuously assessing psychosocial needs, which can often be quite fluid. We're getting to know families to a greater level than ever before. Onda times supporting them through traumatic events. It is not uncommon to have patients with family members diagnosed, struggling and losing their lives due to co bed Sarah. How is the Cove in 19 Pandemic changed how you communicate with our patients and families. As I just mentioned, there are new challenges in communication due to isolation. Precautions were now restricted from patient rooms and unable to complete in person face to face assessments. The care team utilizes technology and bedside tablets to communicate with patients, especially on med search floors. There is an increase in updates being provided via phone by all members of the interdisciplinary team in the I. C U are Critical care team spends the majority of the time in communication directly with family. If alert and oriented, our patients are often too sick to complete. A full assessment on our primary priority is to identify a surrogate decision maker or determine if a patient has completed a health care directive. Our nurses have taken responsibility for facilitating video calls at bedside so families can see their loved one. We have made visitor exceptions for goals of care meetings, on withdrawal of care or for end of life as a unique way for families to feel a connection to their loved one. I have asked families to email photos to be hung up in the patient's room. Also, we have utilized a gift that historically was used for patients nearing end of life as a way to connect patients with their young Children. This was initially a program that was taken or adopted from our palliative care team. This gift is, ah, heart module that the nurses air able to record the patient's heartbeat on, and we give the modules to families to put in a stuffed animal or other keepsake. Patty, Joe and Sarah what additional challenges do the patients and families endure? When a loved one is hospitalized with cove, it well, many challenges emotionally, that can that can include despair, loneliness, fear and depression. Some are. All of these emotions are present in all of co vid positive patients and families due to the unknown changes in medical status, but mostly because of the isolation and lack of in room support from family and, um, other loved ones. When patients that are elderly come into the hospital, the longer the hospital stay, the more emotional support patients and families need to cope with illness and the isolation. And if a patient comes in with mild dementia and becomes more confused, that person who was once fully functional toe live at home with their spouse is no longer able to return home. And that takes a toll on the families as well. When a patient can go home and can return to the family without any other needs other than, um, PPE, they have concerns about obtaining and paying for the needed PPE. In order to follow guidelines to prevent infecting family members, they may expect the hospital to provide PP, which is not a viable option. Assistant patients with this discharge need can be time consuming and at one time was not possible at all. If families were given a choice and they're and they're able to bring their loved one home, most of them would choose that option. But due to lack of resource is many families do not have that option. And they are in a position to have their loved one discharged to a skilled nursing facility that may have a lower CMS rating. And then that causes Mawr emotional stress because that decision is not the one that they would choose if they were in a different situation. Sarah, would you like to add? Sure. Like Patty Jo had said, we've seen both patients and families struggle with isolation, despair, loneliness, fear and depression, among other emotions. Patients, often those who are elderly, stay in the hospital longer due to co morbidity, ease and complex discharge needs. There's a visual or even tangible correlation between not having family visit and the emotional and physical toll that it not only creates for the patient and their family, but also for staff. In addition, on both Met Serge and critical care units. We have seen extensive financial challenges on Med Surge. We have seen patients struggle to afford medication and pay for transportation home on both units, we've seen the struggles families face when the primary breadwinner is hospitalized. Social work has assisted in connecting families with community resource is and completing financial assessments to determine eligibility for charity funds through the hospital or national organizations. Sarah, can you tell us why Advance Directive is important for our covert patients? Yes, on both med surge and critical care units are Team offers patients who are alert and oriented theon Pertuan ITI to complete a health care directive. We provide education on advanced directives and guidance on how to complete the document. Patients who are not interested or informed of who their surrogate decision maker would be her state statute in the event that the patient becomes incapacitated during the course of their hospitalization on the critical care unit. One of the toughest challenges I'm facing is identifying a decision maker. Many times I'm racing to complete a health care directive with a patient within a few hours of the patient being intubated. If a patient is not alert and oriented I'm calling their emergency contact to obtain as much information as possible and identify a surrogate decision maker in contacting that individual to determine whether or not they're willing to serve in that role. The medical team is notified as soon as a decision maker is identified. Patty Jo What are some of the socioeconomic challenges that Cove it presents? Patients and families faced with lack of financial resource is are faced with, um, Mawr stress at time of discharge because they're not able to make the choices that they would normally make. If they did have. The resource is not only do patients want to return to their own homes, families want them at home as well. But if the patients too weak and become a de conditioned, this may not be an option. If patient does not have 24 7 care given by another family member and they're unable to for private caregivers, they're put in a position to choose a discharge plan that is less than desirable. This could be a barrier to discharge and takes a lot of the health care staff to work on creating and making them feel as well as possible with the decision that they make for their loved one. Many families declined the recommendation given to them at discharge because they're put in a position to choose a skilled nursing facility that has a low CMS rating. As these are the only ones available and accepting patients who are covert positive. They feel hopeless because they're concerned about poor care, not being able to check to make sure their loved ones are okay and receiving adequate care again. More stress to the family and the patient. When patients are not close to their home and their transferred over because they don't have, they need a higher level of care. They may, when they return to their homes, they may not have. The resource is in the area that they need. For example, they may not have home health because they're in a rural area that it's just not possible. This creates added responsibility and concerns for the family. How are they going to bring their loved one home? How are they going to get the loved one toe outpatient therapy? So there's a lot of working with patients, families and supporting ah discharge plan that can work for them to get to their home, and that's not always easy, I. There's also just social issues caused by the complicated cup caused and complicated by the pandemic. By Uprooting families, especially the low economic population, lack of resource is have forced patients to move in with their Children or other family members. Families have had to rearrange their lifestyles to care for loved ones that once were independent and had their own lives. As you can see again, Mawr stressors more psychosocial issues, and we're very thankful for the social workers that help us deal and support our families and their patients. Could Stacey How is Cove in 19 displaced patients from the residential facilities? So residential facilities include assisted livings and group homes and really everything in between? And they've been hit hard by this pandemic. So what we're running into is patients coming into the hospital because they have a covert diagnosis and the place of residence is declining to take them back into the home. So then we're faced with a place patient who is temporarily without a home. Now what we need to do in this situation is thio work with these homes to determine. Is there a way that we can help them taking a resident back. Also, we need to explore skilled nursing facilities that will accept somebody who has cove it. We need to work with families and identify any resource is that they might have. Are they able to take their love going home with them? Are they able to hire caregivers? So we really have to get creative in this situation. And it's also very important to be aware of the the local policies. For example, in our area, we had an executive order that instead that these facilities need to have a plan to take their residents back. So when we run into this issue, we simply remind these facilities of the executive order and also work closely with them to make this safe. Is it education that they need? Um, do they need? Resource is for finding PPE. There have been some shops identified that will sell to really anyone. So it's just working closely, thinking outside of the box and identifying, uh, different, whether it's temporary or long term placement for these patients and always having a backup plan. Stacy, what are some additional challenges that exist in obtaining these resource is due to cove, it so limited, um, providers is definitely a reality for us. I think that this is something that case manager struggle with before a pandemic. And now we're faced with understanding who will accept somebody who has co vid currently who will accept somebody who is considered covert, recovered and actually identifying what definition of those are they using? So there's many facilities that have specific testing criteria, um, timing criteria, all sorts of things that different providers are following. And again, we need to work closely with them to follow those and get patients safely discharged. There's also limited staffing in the post acute setting. Due to exposures. There are limited beds, limited chairs. Um, there's covert units available, but those beds fill up the outpatient dialysis chairs, and a covert unit can fill up a swell onda. We've also experienced this with in patient hospice units, so sometimes it's a waiting game. Sometimes it's working on a backup for these patients to get them where they need to be sooner rather than later. Oxygen is a very common need for Covic patients upon discharge, and we've had to change some of those work flows as well. So due to limited visitors being allowed in the hospital and also the sustainability of having somebody come in and do education on all of these patients, we had to come up with something new. So our bedside nurses learned how to educate patients on this equipment so that we could quickly get these patients home so that they could rest and recover with oxygen without waiting on somebody to come in and educate them and make that delivery. Transportation has been quite a challenge on this is a matter of reaching out to identify who will take these patients what they require. Um, for a while we had to explore is an ambulance the only option? Because they're the only company willing to transport somebody with Cove it. But then, eventually there are more providers willing to do this, and it's just working closely with them to identify those resource. So, Stacey, what about patients who are discharging to a post acute facility? We got a lot of questions from family about what that's going to look like. What is that safe? Were asked often, How can you make sure that my loved one does not get co vid in that facility. And unfortunately, we have to explain that way cannot guarantee that their family member will not get Corbett. Whether that's in a facility or in the home. We can only do our best to prevent spread of this disease. So, uh, we also encourage them to really work closely with these facilities to understand what they're doing to prevent the spread because every facility is doing something differently. So we get the families in contact with them early on so that they can identify if they're comfortable with the measures being taken. And we can educate them as well on the CDC guidelines so that they can make an educated decision but understanding that we certainly can not guarantee that their loved one will not get cove it. We also like to discuss with them a communication plan. There's a lot of post acute facilities that are allowing window visits so they might not have seen their family member for weeks months because they've been in the hospital. But then when they go to a skilled nursing facility, they're able to sit outside of the window and visit them. There's also facilities that have technology to allow video chats between patients and their family or friends, so identifying the process is for the individual facility and then setting up a communication plan is very helpful for patients and families. So Stacy, how do you keep track of which post to keep providers will accept covert patients. So my role is that are in care management Liaison is to act as a liaison between the hospital and these outside providers. So really having one dedicated staff member toe organize all of these resource is is key. Frontline staff are caring for patients there supporting families. They're actually formulating the plans for each individual case. They're just not able. Thio search for all of the resource is as well. So having a point person for these resource is is essential. We have a shared spreadsheet of each different arena. So whether it's still nursing facility, home health, Long term care hospital, um, we have a spreadsheet to keep track of the contacts for these organizations as well as the cove it procedures that they're following so that we know in order to send to this facility, you need to follow X y z So this person can also get involved with those problematic discharges that there's a barrier between the hospital and that facility. This person can really step in as a third party and mitigate any of those issues in order to move forward with the safe discharge plan For the patient, this requires a lot of calls, a lot of emails in order to keep up to date on the most frequent information. Because, as we know, this all changes very quickly from minute to minute as you. Whether or not a facility has space for a patient or if a home health really has the caregivers to go in for covert patients, covert recovered patients or if they're not accepting them at this time. So really having one staff member to keep track of all of these different resources is keep thank you, Patty. Joe, what is assisted? Um, you, as you've worked through the discharge planning process with the covert patients. Alrighty. On our med search floor, we have daily rounds, um, collaborate with the health care team, which can include physicians, the care management team, dietary, the our floor, uh, team lead, and the manager as well as therapy and we gives us a time to discuss the possible barriers and that are many. They can include financial resource. Is lack of financial resource is limited. Choice for skilled nursing facility As Stacy just mentioned home hell, some home health are able to have our and go out, but not physical therapy. They're not able to return to their assisted living facilities. Um, each assisted living facility seems to have their own set of criteria. Group homes may not accept him back. And then what was already, uh, talked about transportation and all of these Concordes, delays and discharge leadership is also at these meetings, so they have a good idea of what the med surge team is up against. Two get a timely discharge and their input is valuable. All of the input is valuable to assist making this discharge happen. And then we have a remote monitoring program because many of our patients expressed over and over again that they do not feel safe going home when they're still testing positive for Covad. They want to go home when they test negative, which can take quite some time. Having the remote monitoring program available has provided them some comfort in knowing that they're not alone, that they will have nurses and physicians that will be able to monitor their progress there available to them at home, because they will be, uh, twice daily putting in vital signs, which includes a pulse oximeter, and then they'll be able to talk to them if they have questions. This program has helped alleviate some of the stress for them going home knowing that they're not alone, it's it serves as a lifeline for the community, and any patient that tests positive for covert that goes home will be will have that ordered for them. Eso that that this is a really good additional resource that helps our Covic patients. Um, education. That just begins at the time of admission are physicians, the primary care nurses, the care management team. All are starting to educate at the very beginning, because there's many questions and fears associated with being positive for Cove. It and, um, they're educating them on safe guidelines for returning home, which is practicing social distance in masking hand washing. And as time goes on, some of them feel better returning to their homes with others that may not have tested positive. Uh, they can't stay in the hospital, which is their choice. Eso we just work with them to make them feel uncomfortable assed possible. And again, it's more education and mawr phone calls working with families and patients, which is labor intensive for all of the health care providers. But necessary. So Patty, Joe and Sarah, what does case management and social work need to do to accept the new normal when assisting with the discharge needs of these patients? Well, a flexible and can do attitude is right up there, um, and then to know that nothing remains the same. Restrictions put in place by post acute providers changes often. Stacy mentioned this. It's minute by minute, day by day. You think you have something figured out, you're ready to go and something changes. It could be the patient medical status. Or it could change the criteria set forth by some of the post acute care providers. The new guidelines and processes that come to us on a daily basis from these post acute care providers makes discharge planning labor intensive and challenging. Uh, patient may be doing well one day, and then the next day the patient may transfer to our progressive care unit or intensive care unit for higher level of care. CME's can Case managers can be told one day that the patient will go home the next day with oxygen, only to find out that all the efforts to put into getting the oxygen and now they are no longer going to be discharged. Eso The entire healthcare team is on a learning curve on how to tackle discharge plan. And due to the constant changes in inpatient status and available resource is med search care managers. Social workers are monitoring statuses daily because of the acute changes that can happen. And again, the communication with health care team and family is necessary for timely discharge planning, lots of communication. Lots of pacing the case. Sarah. So, um, add on toe what Patty Jo had shared. Um, our roles within care management have always involved being creative and solving problems with no prescriptive solution in the setting of co bid, the patterns and formulas that we've used in the past have been disrupted. Um, the equation is different, but our techniques remain valid techniques involving communication, persistence, open mindedness and enthusiasm to achieve success and provide excellence in patient care remains the same. So Petty Joe and Sarah and Stacey, do you have any final thoughts for those listening today? Well, we all can agree that Karen for coverted patients is challenging. Um, for the med search floor, uh, start early in the hospitalization for a safe discharge plan. Identifying the resource is that will be needed based upon the unique situation of every patient that we are working with. Um, but for me, I found that, um, to recognize that regardless of individual roles of health care, team needs of patients have become more challenging. And what was once our stable routines and established previously have changed abruptly supporting each other, our families is very important, but supporting all of the health care workers that we work with on a daily basis that are all feeling the stress of working with the population, whether it's emotional or just coming up with a safe discharge plan. So we all know it's labor intensive, regardless of whether which floor you're working on and the emotional toll that it's taken on those of us who work daily with this population is something that we're thankful that is recognized by leadership and having that support of leadership is extremely important in orderto keep coming back day after day and doing what we do best, which is good patient care. Yes, at toe What Patty Joe just said, You know, being supportive of each other and other members of the health care team is especially important right now on the critical care unit were in the process of developing programs to help patients, families and staff, such as a virtual support group where families can engage in open processing with each other. In addition, I have partnered with the unit chaplain to create a tee time for staff toe, promote inter unit socialization and a safe space to process. Um, last week we had our first moment of silence during morning huddle toe honor the lives lost and acknowledge our unity and strength as a team to move forward through whatever the next week will bring. This will be an ongoing weekly event, and in the setting of co vid, we're all at a heightened risk of burnout. Um, it's important to communicate with each other. Um, reach out to your leadership if you are a coworker, are struggling. Explore employee assistance programs. If that's available within your organization, Onda recognized the importance of self care. We're all in this together, so I would just say, Really, knowing your resource is be willing thio, get creative and negotiate and remember that you're dealing with humans on the other end. So post acute providers. Um, there's fear in the community. There's lack of education here and there, so be willing to communicate a little more to provide education. Andi, just to be creative things are not going to work as well as they used to in areas where they were. And that's that's just the way that it iss so really just continuing to be kind. Um, that goes a long way and always have a backup plan. So I'd like to thank say thank you to our Panelists today. Also thank you to those who are listening today
