Issue 38 – Transitions

“How is everyone today?,” the Transitions Coordinator took out her notes smiled at everyone gathered in the room. “We’re all doing well,” James said on behalf of his father and siblings. James had arrived yesterday, and John felt better that both his siblings were here for this meeting.

“As you know, I met with Hazel. She’s doing quite well considering…,” the Coordinator’s voice trailed off for a moment but she came back to say, “but there are some concerns.” Charlie gave her a puzzled look. “Like what?,” he asked.

The Coordinator collected her things in front of her and continued. “Well, we need to look at some higher level care options for her. She isn’t very mobile, and her mini mental assessment pointed to some cognitive issues. How has her memory been?” Catherine was the first to respond. “I noticed mom was starting to forget things a while back. She wouldn’t remember certain bits of information and then there was the incident with the forgotten groceries in the toy bench.” The Coordinator nodded and made some notes, “Yes, that’s what I had thought. So this is nothing new?” Charlie was growing concerned, “Well, we’re not really sure what ‘new’ means. Hazel hasn’t been remembering things very well the past few days, but she’s on a lot of medication. She’s not normally like this.” The Coordinator continued to take notes. “I see.” She stated bluntly. “I am also concerned about her nutrition. She has lost quite a bit of weight since being admitted. And then there are concerns with her mobility.”

Charlie raised an eyebrow. “What do you mean?,” he asked. “Well, she is having issues self-ambulating and needs assistance getting to the washroom.” It was Catherine who chuckled this time. “Um, mom has two broken ribs and is on a lot of medication like dad mentioned. As well, she’s been losing weight because it’s hospital food…and I’m sure with the pain she’s in, eating doesn’t feel all that great.”

At this point, John stepped in. “So, what’s the plan?,” he asked. “We are looking at some higher level supportive living options for your mom that could meet her specific care needs,” the Coordinator took out some information she had prepared for them. “And you’ve talked to mom about this I presume?,” John asked skeptically. “We had a brief chat about it when I met with her earlier. She was very concerned about how this would affect the move to the new place.” Charlie nodded, “She’s not the only one.”

“But wait a second,” John interjected. “You’ve assessed mom while she’s bedridden. Surely you must be aware that this is not going to be her long term state. I’m sure many of us would have issues with a mini mental assessment on strong pain medications, and we’d have trouble moving around with injuries. So, if she moves to a higher level of care, gets better, and then no longer needs that level of care, what will our options be?” Charlie, Catherine and James all shook their heads in agreement. “That’s exactly right,” James added. “Mom and dad have already arranged to move into a place that offers some supports. Couldn’t we organize to have someone come in to help mom ambulate for the next little while? And shouldn’t we maybe assess her when she isn’t doped up on medication?”

The Coordinator put her pen down and thought for a moment. John continued, “There have to be other options…surely, a permanent move like the one you are suggesting isn’t our only choice here.” The Coordinator nodded, “I understand the concerns, but the assessments are done for a reason. Our goal is to support Hazel – as our patient.”

“And our goal is to advocate for her – as our MOTHER,” John quipped. “I suggest you assess her when her condition has stabilized instead of basing her care needs on her immediate and very temporary condition.”
It can be difficult to assess what a person’s care needs are when they are still experiencing severe health issues, especially if those issues are temporary. Far too often, seniors are moved into higher levels of care, only to have their health improve to the point that very few supports are needed.

What do you think of the present situation? Do you have any comments or suggestions you’d like to share? We’d love to hear them.


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