Care Situations

Care Situation 1:
Martin is 62 years old single male, never married. He lives with an acquired brain injury as a result of a work accident in construction when he was 37 years old. The Worker’s Compensation (WCB) program provided coverage and arranged a series of rehabilitation programs, but these ended after many years of service, as rehabilitation potential was not anticipated. Martin has both physical and emotional health conditions. Martin has an organic personality disorder, causing him to exhibit outbursts of temper and impulsive behaviour. Physically, he has mobility impairment from the head and orthopedic injury, and depression as a result of his disabilities. He has an uncoordinated walking gait with limp and occasional spastic movements. He uses medical marijuana for pain and spasticity and occasionally uses alcohol. He has been convicted of assault and mischief once, and public disturbance on a number of occasions. Martin lives alone in a subsidized apartment. He has a friend who visits from another area and stays a few days a month with him. Martin’s family in Ireland would like him to come home but they are worried about his unmanageable behaviour, which could impose risks to both himself and family members. They continue to stay in contact with him. Martin has three siblings living in the province that will have nothing to do with him. Financially, he has a settlement from the WCB that provides him with $1,500 per month as an ongoing arrangement. His financial affairs are managed by the Public Guardian and Trustee Office.
Martin spent one year in an inpatient rehabilitation program, three years in a live-in vocational training program, and 4 months in jail for assault (5 years ago); he has ongoing community supervision by a probation officer. In the past, he had a community care manager contracted through the WCB program, but this was terminated when Martin went to jail. He has now been referred by his physician for care management through the Home and Community Care program because of his need for additional home and personal care supports. He also requires increased support for mobility and vision impairment. You are the care manager who received this referral.
Assume that you have been assigned as Martin’s care manager.

1. What values, beliefs, and assumptions would you bring to this situation if you were involved as a client-directed care manager and member of Martin’s care management team? Consider personal and professional values beliefs and assumptions.
2. As Martin’s client-directed care manager, how would you prepare and then proceed in engaging Martin? What supports and resources would you require? What challenges would you face, as a care manager, in providing a clientdirected approach with Martin?
3. Discuss the definition of client-directed care management and the role of the client directed care manager, relating it to Martin’s situation. Apply the principles of client-directed care management to your discussion.
4. Describe the eight (8) care management activities that you would provide. For each activity studied in the course, describe what it is and how you would apply the activity in Martin’s situation. How would you ensure that you are clientdirected in your provision of these activities? Consider and integrate the Canadian Standards of Practice for Case Management (NCMNC, 2009).
5. Choose two models of care management, and explain the similarities and differences of the models. Explain how you would provide client-directed care management for Martin with these models (address each chosen model separately).

Care Situation 2:
Linda, who is 53 years old, was diagnosed with Multiple Sclerosis (MS) seven years ago. She experienced a severe depression and a suicide attempt by overdose shortly after she was diagnosed. She was treated by her physician with consultation by a private psychiatrist. She remains on antidepressants. She has a good relationship with her family physician. Linda is in a long term lesbian relationship with a woman she has known since high school. Although they do not live together Gwen helps Linda with shopping, transportation and other activities. Gwen has acted, with Linda’s permission, as a health advocate for her in the past. Linda’s health condition has been stable until recently; however now her transfers have started to become unsafe, and she has had several falls while using her wheeled walker. She has called her local community health center for help. Given her needs, Central Intake Services sent the referral to the community occupational therapist, Cheryl, to visit Linda. Cheryl completed an assessment and provided recommendations to assist Linda to manage safely in her home. Her recommendations include mobility safety with the walker and safety with transfers, as well as changes to her environment and equipment recommendations to assist her as her condition deteriorates. However, Linda expresses that she is frustrated and she starts to cry. She is angry and yells at Cheryl stating “I do not need to make my home safer; I need to be able to walk. I want a physiotherapist”.

1. What model(s) of care management is Cheryl most likely working from? Provide support for your answer.
2. If you were Cheryl, describe the care management activities that you would provide for Linda’s care situation. How would you ensure that you were clientdirected in your provision of these activities?

The same day, after Cheryl left, Linda fell in her bathroom. She called the nonemergency fire and rescue to get her up. She had them take her to her elderly mother’s home nearby. Her mother has severe osteoarthritis and cannot take care of Linda, so her mother called Cheryl at the community health center (CHC) for help. However, Linda is refusing to have Cheryl or the staff of the community health center involved because “you did not send out a physiotherapist to help me walk again, and that is why I fell”. She also states “I would be better off dead than to have to live like this” and “I am a burden to everyone and I will just become a bigger burden if I cannot walk”. Linda’s mother tells Cheryl that Linda cannot stay with her. Gwen, her friend, lives in a small one bedroom apartment in Co-op housing and cannot have Linda live with her. Cheryl is concerned that Linda needs more care, including a mental health assessment and asks Linda to call her doctor. Linda refuses, and tells Cheryl she does not want the Dr. involved.

1. What are the ethical, professional, and legal issues that Cheryl faces in this situation?
   a) What ethical decision(s) must Cheryl make?
   b) What types of legislation support Cheryl’s client-directed care management practice for these decision(s)?
2. Using the ethical decision-making process: • What is the ethical dilemma in this situation?
   • Consider who should be involved in making the decision(s).
   • Indicate what the facts are.
   • Analyze the facts using the bioethical principles.
   • Do all principles point to a single course of action? Why or why not?
   • What options, or courses of action, are possible in this situation?
   • What seems like the best option/resolution for Linda?
   • If you are Cheryl how will you monitor and evaluate the outcomes? Support your answer from the perspective of a client-directed service delivery approach, using ethical and current legislative principles.
3. Using the Canadian Core Competence Profile for Case Management ( NCMNC, 2012) identify and discuss two core competencies that apply to Cheryl’s decision to call or not call Linda’s Physician. Indicate how Cheryl could meet the competencies you have identified.

Care Situation 3:
You are the Nurse Practitioner (NP) working for the health authority responsible for health services in a remote northern area of the province. This is your first posting to the role and to the area. You have received a call from an RCMP officer in the closest town (100 miles away) who was contacted by satellite phone by the family of an elderly woman. They are concerned about the woman’s health condition. The health center for their community has been closed because of lack of staff and recent flooding in the area. The village is only accessible by ATV, boat or plane. The only physician for this area has recently retired. They have contacted the health center in another area but the health center says they are unable to provide services for anyone other than their own area population. The woman’s name is Elsie, she is 82 years old. She has lived in this remote aboriginal community all her life. Elsie is an Elder in this community. Elsie is reported to have abdominal pain, confusion and memory impairment. She has been relatively healthy most of her life other than having breast cancer 12 years ago when she had a mastectomyin the nearest city (700 miles away). She has not had any follow up since the mastectomy. She has become significantly vision impaired due to glaucoma. She does not want to leave the village using the plane that delivers supplies and provides transportation.

1. If you were the Nurse Practitioner who received this phone call, what values, beliefs, and assumptions would you bring to this situation after hearing the information ? How would you prepare yourself to work with Elsie in this remote area?
2. Is Elsie a client? Discuss this in terms of specific care management activities, ethical considerations, and legal principles.
3. Discuss the system issues that are raised by this phone call. What factors are contributing to the families call for help?
4. If you could change the system to better meet Elsie’s needs for comprehensive care and continuity of care, what level(s) of system change would you address? Integrate population health and chronic disease management concepts. Consider cultural beliefs.
5. Describe client-directed health system change elements and strategies that will address the issues in this remote rural area and promote a seamless client-directed health system. Be creative, use diagrams, tables, or other visual aids for added value, and portray your proposed ideas that will promote client-directed health system change for seamless client-directed service delivery.