Caregivers Primer

Caregivers - Knee Replacement at 86, Part 5 - Pre-Admissions Testing

It's been a very busy week.  Mom had three appointments scheduled in preparation for her surgery next Tuesday.  I had three doctor's appointments of my own, plus a trip to the shop to get a directional light fixed.  I can't wait for Saturday to get here. 

Monday, we met with the surgeon's PA (physician's assistant) to go over mom's medical history and medications.  I made sure that her Personal Medical History (see Pages in the sidebar) was up-to-date and printed a copy for the meeting. 

My main concern was a medications she might have to stop days before the surgery, like blood thinners and some types of diabetic medications.  She was fortunate that she wasn't taking any of those types of medication, and the PA's only caution was not to take aspirin, or ibuprofen, or any other anti-inflammatory drug over the counter.  She was to stick to her regular pain medicine and Tylenol-type pain killers.

He noted her allergy to Penicillin and her contact allergy to latex so those would be communicated to the doctor and his operating room nurse.

Friday is going to be a long day as well. At 8:15, we have an appointment at a lab for fasting blood tests.  We are fortunate that one area diagnostic lab chain is not taking appointments.  You can go online and schedule, change, and cancel appointments.  It has been wonderful and there are no more packed waiting rooms and 45 minute waits.

After that, is the pre-op interview at the hospital.  I don't know why we have to go.  Really.  A woman from that office called today.  Even after my mother explained she couldn't hear well and said the woman should call back when I was home...and after the woman made sure we knew we had a pre-op interview in the morning  (P.S. she gave mom the wrong time for the appt.)...the woman still proceeded to ask her all kinds of questions that were supposed to be covered in the meeting on Friday.  One strike.  I'm going in fussing in the morning, believe me.

But this is the list of what we should bring.  If you or your loved on has surgery and they don't tell you what you are going to need, this list should help you.

*  Allow at least 1 hour for pre-admissions interview and longer if you doctor ordered any tests to be done by the hospital.

*  Bring your IDs:  Insurance card (including Medicare/Medicaid if applicable) and Driver's License or valid Picture ID

*  Most hospitals require your co-payment, if any, to be paid at this pre-admissions meeting.  Be sure to check with your insurance to determine what your co-pay will be and have it ready either with cash, your checkbook or credit card.  (note: You may want to call the hospital ahead of time to see if there are any restrictions on personal checks or the types of credit cards accepted.  Others may not accept cash.  Be sure BEFORE you go to reduce any embarrassment or delays.)

*  If you or your patient does not speak English as your native language, it will be your responsibility to provide an interpreter.  Do not assume the hospital will have someone to help you.

*  If you are acting as your patient's representative, or they cannot speak for themselves because of their condition, be sure you bring one or more of the following documents, as applicable:  Durable General Power of Attorney, Directive to Physicians and Family, Living Will, or Medical Power of Attorney.  (see Pages in sidebar)

*  Bring the patient's (you or your elder) Personal Medical History.  If you update this after your last visit to the doctor, everything else the nurse or admissions people will ask is on the History, including medications, allergies, and health history.  Don't forget to include any over the counter (OTC) medications you might be taking, including vitamins, OTC remedies or herbal treatments.

*  If your primary doctor has not already sent the medical consent for surgery to the surgeon, be sure to stop by their office and ask for copies of any required consents for surgery.  These usually include the doctor's assessment of the patient's physical condition, a chest x-ray, and an EKG.

If you plan ahead, you'll have everything in order and can answer any questions the hospital staff might ask.  The better prepared you are, the easier the meeting will be for you and the hospital staff.  They will love you for being organized and thank you.  Believe me, it has happened many times for us when I handed them the Personal History which included everything neatly organized and labeled. 

Take care of yourself and those you care for....

Kathy F

Caregivers - Knee Replacement at 86, Part 4 - Our Rehab Selection

Well, we finally made our rehab decision for Mom's recovery.  I spent Wednesday morning visiting several rehab centers to see their facilities and get a tour.

See the post "Caregivers - Choosing a Rehab Center for Your Elder" in the category Rehabilitation Centers for suggestions on selecting a rehab center.  Be sure to check the comments as well for additional advice.

One facility my mother had been to before and it was totally unacceptable, from bathroom doorways too narrow for a wheelchair to aides that didn't speak English well enough to care for English-speaking patients.  Two others I knew about from word of mouth but I checked them out anyway.  One seemed overcrowded, short term rehab patients mixed with long term care, some patients were put in wheelchairs to get them out of bed, but they were just left along the hallway, either staring off into space or calling out for help and being ignored.

We quickly narrowed the choice to two facilities I'll call Elms and Oaks. 

Both facilities are neat and clean, nice common areas, like dining halls and fully equipped nurses stations.  Both had separate wings for short term rehab and long tern nursing care.  Both had large two-bed rooms with large bathrooms and roll in shower.  

The Elms is the newest in the area with really nice public and common areas.  The whole atmosphere is light and bright.  Not a hospital setting.  Comfortable, with a phone at each bedside, a beautician that comes in once a week to wash hair and do nails.  They have a fully equipped physical therapy room and activity room.  I was pleased with the multiple menus at each meal with an attention to detail in nutrition therapy.  There were a number of other amenities, though most would be things Mom wouldn't need for her short stay of 2 weeks or so.

The negatives:  The physical therapist was real busy and I was unable to talk to him.  I worried about security.  Only one person was at the front desk and was not always there to control access.  At night, a side entrance is used but there was no real security there either, not to prevent someone from coming in or for a patient from wandering out.   

The Oaks is the oldest facility in town but was sold to a new owner, gutted and redone.  The occupational therapist even has a sink and microwave that patients can practice with to help them be more independent when they go home.  The staff was very friendly and I had received a recommendation from one person who knew the occupational therapist.  I was able to meet with the staff and talk to them about the plan for knee replacement recovery so I would know what to expect.  Security is very good.  You have to be buzzed in and only the staff have the code to get out.

The negatives:  Older building.  Smaller facility.  Two outside areas but very cramped with high fences. The therapy room is small, with less of the expensive equipment of the Elms but Mom wouldn't be using much of it anyway.  No activities center or beautician which Mom could use.  They can't order the ostomy supplies we need.  

Decision:   We decided to go with the Oaks.  While the Elms was my first choice, and despite the lack of therapy equipment, we liked the more homey feel of the smaller facility and the nice therapists that would be working with Mom.  I was certain that's where we were going to go.  As with one of the comments on my related post, people are the key, and that seemed to be the correct choice.  That was our decision until Friday afternoon when I called back to ask a few more questions.  

Then the deal breaker.  The Oaks did not have a phone in each room.  Mom would be isolated with no way to reach me because the only available phone would be a portable phone at the nurses station with no volume control.  Because of my own disabilities, I wouldn't be able to visit each day for long periods of time, so communication is very important.  The director suggested I buy a cell phone with a one month plan with a volume she can hear, but that is not feasible for our situation.

Conclusion:  I will be going back to the Elms on Monday to review the situation once more.  I'll ask to spend a few minutes with the therapists,  I'll talk about security, and ensure that her supplies can be ordered in the brand she uses.  Once that is firm, we will give them the decision that we will be choosing them so that they will hold a bed for her for the date we expect her to leave the hospital.  It's confusing, and exhausting, and a little strange to think that one small item, like the phone availability, would be the determining factor, but it was. 

Everyone has different needs and requirements.  We looked around until we found the rehab with what we needed and wanted.  I wish you all the best in finding the one facility that meets your needs.

Take Care

Kathy

Caregivers - Knee Replacement at 86, Part 3 - Choosing a Rehab Center for Your Elder

Today, I went out to evaluate some rehab centers.  Mom's knee replacement surgery will be Oct. 21 and I needed to decide where she will go after the surgery for therapy. 

There are seven rehab centers in out area.  Mom went to one of them briefly last year and it was a disaster so we counted that one out quickly.  I asked my physical therapist for suggestions and she picked three.  One of them is closest to us but is mostly for long term care and reminded me too much of the poor quality facility my father was in when he passed away.  I knew mom would hate it, even if it was very convenient.

The other two were nice, but different enough to give me a hard choice.  Each had good points and bad ones.  

I used a list of questions I worked up from various sources and our own situation to make my decision.  These aren't in any particular order except number 1.

1) First, call the facilities you want to visit.  Ask the receptionist about coming in for a tour and check the hours.  Be sure to get the name of the person you will be asking for.

2) If your elder is going to need therapy of any kind, physical, occupational or speech, start with the therapy area.  Look over the equipment available.  Ask questions of the therapist on duty to see what they would do for your patient.  In our case, one therapist described what the initial assessment would be like, what the different goals would be for my mother, like moving the knee to a certain angle, then getting up, using the walker, etc. 

3) General cleanliness, atmosphere.  Some facilities have beautifully decorated reception areas and dingy rooms and dining areas.  Check all the common areas.  Are patients stuck in wheelchairs and left sitting in the hallway, calling for attention, or are there activities and content residents?  Is short term, rehab care on a separate wing from long term care?  What is the nursing ratio to patients? 

4) Is the dining area clean and inviting?  Is it crowded?  What is the ratio of aides to residents at meals (if your elder needs help, is it available)?  Is there more than one offering at a meal?  How are likes, dislikes, and food allergies handled?

5) Patient rooms.  Check to insure there is a call button at the bed and in the bathroom.  Is there a walk/roll in shower?  Is there leg room under the sink for wheelchair access?  Are the bathroom doors wide enough for walkers and wheelchairs?

(This is not a foolish concern.  My mother's rehab a year ago had just been reopened after reconstruction.  It had been damaged in the 2004 hurricanes in Florida and had been gutted and rebuilt, but no one had been smart enough to remember patients in rehabs and nursing homes use wheelchairs.  That was one of many problems and I signed her out after 3 days.) 

6) What kind of security does the facility have?  (I found one with an open front door and an open side door at night.  Neither one had a full time attendant.  You have to wonder who could just walk in off the street and if patients could wander off without being noticed.)

7) What provisions do they have for patients with vision, hearing or language concerns?  My mother is legally blind and has diminished hearing.  She also needs to have nursing and therapy care from someone who speaks English very clearly because with her poor hearing, she can't understand anyone with a thick accent, which is common in our area.  

8) What can or should your elder bring with them to rehab?  I needed to know what to pack for her transfer from the hospital to rehab.  For therapy, will she need exercise clothing?  Will she be able to wear her own gown and robe?  Should she bring her own wheelchair and walker or will they be provided by the facility?  If she brings her own equipment and clothing, how should it be marked? (My father was in a nursing home for nearly two years before his death.  Even though his clothing and belongings were clearly marked, any of them disappeared.  I found his quilt on the lap of another wheelchair patient and when I questioned the floor nurse, she became belligerent and defensive, asking how I could be sure.  Since I created the design and quilted it myself, and wrote a message on the back with his name and mine, she had to admit that it was his.)

9) Does the facility have insurance for theft or damage?  After my father's Alzheimer's had made him unaware of his surroundings, his expensive hearing aide was dropped an stepped on my one of the staff.  We found it in a paper cup in his nightstand in pieces.  No one would admit to the accident and without him being able to respond to a hearing specialist to create a new one, he became even more isolated by his deafness.

10)  Insurance coverage.  Be sure you know what your patient's insurance will cover and for how many days, so you won't have any unpleasant surprises.  Medicare requires an in-patient rehab to have daily access to a physician and 3 hours of physical therapy per day.  If you have supplemental insurance, they may have restrictions of their own.

11) Ask about special medications and supplies.  If your elder has a specific medication need, like mom's Forteo, an osteoporosis medication in an injectable pen, you need to find out if the facility can order it.  Mom's medication is expensive and not normally available through pharmacies.  It has to be a special order.  Will you need to bring the medication from home?  Supplies may also need to be checked.  Mom has regular deliveries of her ostomy supplies and has tried many types and brands over the years.  She has only found one that works for her, so I had to ask if they could order those supplies from our regular medical supply provider.  (Hospitals, rehabs, nursing care facilities, and even home health care agencies are responsible for providing these supplies under Medicare.)

12) Get a card from the facility representative.  You will need to know what to tell the case worker in the hospital so they can contact the facility when your elder is ready to be transferred.  (Note:Medicare does not cover transfers.  If you cannot transport your patient in your care, you may need to contact your nearest council on aging for the names of volunteers, non-emergency ambulances, etc.  Your hospital case worker or the facility administration may also have services you can call.)

13) Ask if the case worker or therapist will be doing an in-home evaluation before discharge.  This is done in advance to ensure that if the patient needs equipment at home, such as a wheelchair or commode chair, it can be ordered and be in place when the patient arrives home.  The case worker will also help you set up home health care if it is needed.

14) Final word.  Once you have narrowed down your choices, be sure to contact your state medical board and your local Better Business Bureau to ensure that the facility hasn't had any complaints.  If you have any fears of abuse, neglect, or even billing disputes, you should cross that facility off your list.  (I would write a letter to the facility naming the problems you found, including any complaints you learned of.  Be polite and tactful.  But the administration can't, or maybe won't, make any changes if they don't understand why you didn't chose them.  They need to know what they did wrong or there is no chance that it will be corrected.)

I hope these suggestions are helpful in selecting a rehab center for your elder.  If you have any other suggestions to add, please comment to this post.  I would love to hear from you.

Take care of yourself and those you care for.

Kathy F

Caregivers - Knee Replacement at 86, Part 2 - Getting Prepared for Surgery

My mother's knee replacement surgery will be on October 21.  While her pain is so severe that i wish it could be tomorrow, I know I need the two weeks I have to get everything done and organized.  

The Orthopedic Surgeon's Office 

Our surgeon's office staff is very well organized.  The lady that helped us determined the day for surgery also set up other appointments and gave us a list of what to bring to pre-op.  She set up an appointment with the doctor's PA for a last minute physical and to go over mom's medical history.  Then she called back, after talking to the hospital ,with our pre-op and surgery times.

When your loved one is facing surgery of any kind, there are some things you'll need to prepare for.  I've put together our checklist for this coming week.

Checklist - Surgery Minus Two Weeks

1)  Legal Paperwork and a Medical History 

Every person you deal with, from receptionist at the x-ray clinic to the floor nurse in the hospital, will ask you the same questions.  I don't care how many forms you fill out, no one reads them.  They just ask you to explain it all again.  

So now is the time to get all that material together.  Look at the side bar for the category "Before Caregiving is Needed."  In the two posts, "Before Your Parents Need Help" and "A Personal Medical History," i cover the different legal documents you should have for everyone in the family.  When you get to the hospital, they are sure to ask if you have a Living Will (also called a medical surrogate, medical power of attorney, and a directive to physician).  If you have one, be sure to have it with you.

In our area, some lawyer's offices are now offering free wills in a package including living will and power of attorney.  Check around to see if there are any similar offers in your town. 

The personal medical history, with the example I have in the Pages section of the side bar, will be vitally important as surgery approaches.  Now is the time to ask your patient all the pertinent information, such as when they last had a tetanus shot, and what surgeries they have had.  The day of the surgery is not the time to ask an anxious elder if they had chicken pox as a child. 

Most important important for surgery is allergies and medications.  My mother is allergic to penicillin and latex.  That affects what gloves the nurses and doctors use.  And a list of the patient's medication is crucial in anesthesia and recovery.  Once you have the history written, you will be able to cut down on the forms you fill out and the multitude of repetitive questions.  (It's so much easier just to write "see attached form" rater than fill out long pages. ) 

Be sure to take one copy with you when you visit your primary doctor so you can discuss medications (see item 2 below) Then you'll need plenty of copies of the surgery version of the history with you for all your other medical meetings and on the day of surgery.  Depending on your patient's condition, you may find that all the questions are directed at you, as their caregiver.  And whenever someone gets ready to ask you questions, hand them a copy to find the info themselves while you concentrate on your loved one. 

2)  

Medical Clearance from Your Primary Doctor 

Since this surgery has been a future possibility for a couple months now for us, mom's doctor ordered her chest x-ray over a month ago.  At her last visit, 2 weeks ago, he did an EKG and general physical, and ordered lab tests.  As her primary doctor, he has to fax the results of the tests to the surgeon along with his clearance that she is physically well enough for the surgery. 

If you haven't gotten some of these taken care of ahead, make an appointment immediately.  Be sure to tell the scheduling person that you have a date for surgery and you need the patient to be seen as soon as possible, preferably by a specific date.  This date will need to be AT LEAST 10 days before surgery to get all the testing done.  To save time, have the primary doctor write the orders for the tests with a request that the results be send to him, as the prescribing doctor, AND directly to the surgeon. 

At our hospital, the requirement is that blood work must be done within 7 days of surgery, so check with your surgeon on this.  Also check to see if your patient must be fasting for the tests.  If so, go early in the morning.

Remember, you will need time for the chest x-ray results to be sent back to your doctor.  If your doctor doesn't do an EKG in their office, you will have to arrange for this as well.  You may have to call around to find a diagnostic center that can do a chest x-ray on short notice.  Many won't have an immediate appointment.  If you have trouble, ask your doctor or surgeon office staff to help you.  Sometimes, a doctor can order the tests to be done at the hospital where the surgery will be done.

Medications---  While you are with your primary care doctor, have your history handy.  Go over your medication list.  Be sure to include any over the counter medicines, herbals, or supplements you take as well.  Discuss what medications, like blood thinners, that must be stopped a week or more in advance of surgery.  Other medications, like some oral diabetes medications, might have to be stopped a day or two before the surgery and not resumed until a day or two after.  Depending on the time of day of the surgery and how long your patient will be fasting, some medicines should be taken with a sip of water so many hours in advance, like blood pressure medicine. 

Have your doctor give you specific directions for each medication and write them down on the medical history so you won't forget them. When you get home, make a duplicate computer file of your patient's medical history.  I usually use the same name as the original file with "surgery" and the date at the end so I still have the original for later.  Don't delete any medication, just make the notations on each one that your doctor altered in some way, and make multiple copies of the new document.  This will tell your surgeon and the hospital staff what you ordinarily take and when you had it last.

(Note: in my information on Personal Medical Histories, I suggest that you do not use personal information, such as SS number and insurance information because you don't want to be carrying that kind of information around with you all the time in these days of identity theft.  But this is one time to break that rule.  The more information on the history, the less you will be asked.  You're the caregiver and your responsibility is your patient, not to answer to the nurse or three doctors what you already answered in admissions, simply because they will not read the hospital file in front of them.)

3)  Insurance coverage 

As a caregiver, you should already be aware what your patient's insurance covers and what it doesn't.  If not, this is the time to check.  Depending on the company, some require advance notice on any hospitalization.  Others may require a second option.  If this is true, you need to know as soon as possible to get an appointment.  Your doctor's office can probably help you get a consultation faster than you can call a new doctor cold and get an appointment.  

Also find out what you will need for a co-pay if any.  Normally, this amount will be collected at your pre-op evaluation so you need to be prepared with either cash, checkbook or credit card. 

Mom's surgery will require some time in rehab for physical therapy.  She has Medicare and they will pay up to three weeks.  Still, I need to call and reconfirm a number of things.  What exactly they will pay for and, maybe more important, what will they not cover so I know what to say no to unless I learn the cost to us?  What is the number of days of care that are covered?  Is there a minimum number of days she must be in the hospital before she can be moved?  How do we move her?  Will Medicare pay for an ambulance or will I need to transport her myself?  What will her secondary insurance pay for and for how long? 

4)  Rehabilitation facilities 

Our surgeon suggested that we get a list of rehab facilities in the area and go check them out.  He will release her to which ever one we want.  Tomorrow, I will contact the physical therapist I went to after my hand surgery, and get some pointers as to what to look for, what questions to ask, etc.  I'll do a post on rehab centers once I learn what to use as criteria for choosing a good one.  

Also check with friends, neighbors, co-workers, anyone how has had to be in a rehab center to see if they were happy with their care.  Sometimes it is just as important to learn what places to avoid as it is to find the perfect one.

 

Surgery Minus One Week will cover the final pre-operation appointments:  The last meeting with the surgeon, labtests, and the hospital pre-op appointment including a list of what to bring with you. 

Until next time, Take Care of Yourself and the Ones You Love.....

Kathy

 

 

 

 

Caregivers - Knee Replacement at 86, Part 1

As my regular readers know, I am the caregiver for my mother.  She is 86, legally blind, and severely arthritic.  Between the osteoporosis and severe arthritic changes in her knees and ankles, she has trouble walking, even with a walker. 

In the last two weeks, she has gotten worse.  First, she was using the walker all day, loading the dishwasher and even doing the laundry, carrying the clothes on her walker to her bedroom where she could sit on her bed and fold them.  She has tried very hard to keep some sense of independence.  One day, she was simply tired and hurting too much, and asked for the wheelchair after supper to get around.  Then she started using it by lunch time and now she's using the wheelchair all day to get around and doesn't walk at all.  It's very painful for her to just to transfer from the wheelchair to the bed or toilet.

Being her caregiver, I need to be with her all the time now.  She is very shaky when she is trying to transfer to and from the chair because she is afraid of falling.  She wants both her mobility back and her independence from me watching over her all the time and waiting on her.  She can't stand not being able to do things for herself.

Her orthopedic surgeon has tried all of the conservative treatments: pain medication, brace, steroid shots, special medication for the joint (I can't remember the name but it was a series of 3 weekly shots, $600 each), and nothing helped her. 

Now, the only option is a knee replacement. 

Mom is understandably concerned about her age and how well she will heal.  Our doctor, on the other hand, is confident.  As he teased her last week:  "I have a reputation to maintain.  I wouldn't offer you surgery if I didn't think you'd benefit and get well."

Knee replacements are more difficult than hip replacements.  We have been warned that the initial few days are very painful from the surgery itself, but that once you are past that stage, and you're willing to commit to the necessary physical therapy, you will be successful and life will get back to dramatically increased mobility in about 6 weeks. 

I'll be writing on her surgery and recovery as the weeks go on, starting with the two weeks before surgery, and telling you about her experiences.  I'll also be interviewing other seniors who have had knee replacements and telling you about their challenges as well.  One person is a neighbor that had the surgery when he was a year older than mom is now. 

We also have several other friends who have had the surgery and some people who have been to different rehab facilities in the area and I will be covering that topic as well.  I'll be getting advice from my physical therapist on how to select a rehab center and then I'll be going to check them out.  I'll pass on the pointers I learn about what to look for.

From Decision to Surgery

The first few posts will be about getting ready.  The plan for "Surgery minus 2 weeks:  October 6-10" is:  

*  Getting medical clearance from her primary care doctor, including arranging the required tests

*  Verifying coverage with the insurance companies

*  Locating and comparing rehabs

*  Updating personal medical history and making copies for all who will asks all those same questions over and over about allergies and medications  (see topic in side bar about creating your own Personal Medical History so you have all that info at your fingertips)

Come back often to learn more about helping your patient or loved one get through knee replacement.  Learn from our experiences, tips, and interviews.

See you soon.  I'm off to cook one of mom's favorite meals.  The Easy Chicken Pie recipe on the side bar made with left over chicken, vegetables, and Stove Top stuffing as a topping.  Simple and delicious.

Kathy