Hello again reader,

Thank you for taking an interest in my blog. Sorry about the formatting on some of the entries. I'm still getting used to the blogger program.

So I promised that I would talk about a client experience today. Well, I'm going to do so, but this time I'm going to describe the experience of a social worker sitting on an Inter-Disciplinary Team (IDT) looking at other professionals and their re-actions to a client's situation.

Again this vignette is from the medical/hospice setting. Picture an elderly lady with mid-to-end-stage dementia and who is living in an assisted living environment. 

In simplified terms, "assisted living/supportive-living" is a residential setting that caters to the needs of the individual by offering for-fee services off of an "a la carte" menu (i.e.- care-giving, dressing, medication reminders, baths, meals, socialization groups, transportation, ect.). There is a movement in America to try to fill the gap between living in one's private home and the nursing home. Assisted living environments are just one option that the commercial marketplace has offered to our elders, and can sometime be as expensive as $2000-$4000+ per month. Obviously, this is not an option for everyone.

Over the last 5 or so years, in my opinion, assisted living providers have become more savvy to the idea of "aging in place". I also subscribe to this idea... why make an elder go through a major stressor, such as moving continuously, when they are feeling less and less control in their lives as it is  Especially, if routine and familiarity to one's own home is the only thing really grounding a person in his/her orientation or capacity to function. Also, I have heard quite a few of my clients grieve over the loss of their family house that they had lived in for 40 some years.

Back to my client. As I sat in the IDT meeting, I heard a nurse explain with frustration that there was a lack of communication/sensativity between the Hospice and the assisted living staff. It seems that the growing pains of the assisted living staff aren't keeping up with the needs of a frail/hospice resisdent. Roll-adjustment is a huge issue here. Let me give an example.

There are many different skill levels for care-givers/home health aids. Some are Certified Nursing Assistants (CNAs), some are more like companions/house-keepers, some have the nurturing experience of their own life experience to pull from. My point is that not every care-giver/home health aid has been introduced to the realities of what is considered abuse/neglect of an elder in the eyes of the state or the medical profession. For example, is the use of diapers on an elderly client. Are the diapers being used for the health of the client, or the convenience the care-giver. How often are the diapers changed? In my client's case, is proper attention being given to how the diapers may be contributing to skin breakdown....expecially when the care-giver thinks it's easier for her to change the client in the future when she puts two diapers on at the same time. *sigh* 

So this doubling-up of diapers pushed some buttons on the hospice team, and from my past experience in nursing homes also tends to push family buttons. It pushed my buttons too, when I saw patients enter a sub-acute floor for physical rehab and for the first time in their life they were put in diapers. These were people who were alert enough to ask for help going to the washroom with the nurse-call button. So seeing this type of decision to put someone in diapers is not new to me.... but two diapers at once.... I have never heard of such a thing. Think of how uncomfortable that must be, and how clamy a person's skin would get? Now imagine if you couldn't verbalize your discomfort?

The nurse presenting the case vented as I said in the meeting saying that she did the best she could at the time to educate the employeed care-giver, but wasn't sure if the instruction would be taken seriously.

I gathered from the feedback from others at the team meeting that a power struggle between the care-giver's supervisor and the nurse ensued and the situation was bumped up the chain of command. The transition of this assisted living environment to a medical environment had not gone as smoothly as was first portrayed.

Also, I think how long this care-giver had been "doubling up diapers" on clients. Was this an accepted care-giver practice in the assisted living enronment?  And since, I know for a fact that other medical agencies had had clients in the same assisted living environment, why hadn't they noticed this "abuse" in the past? Did the need for sustaining a "good" business relationship with the assisted living environment prevent the exposure of systemic deficits? 

Lastly, when one agency criticizes the actions of another agency, and they have to continue working together, how do you go about mending that realationship? My hopice agency advocated for the proper treatment of the client, but we had to basically shoot ourselves in the foot to do it. Don't get me wrong, the client's welfare is always the most important issue. 

Just something I was thinking about today.