Successful discharge planning is not something that should be initiated when the patient is ready to go home, but should be discussed prior to the surgery being performed if possible. The total hip replacement that Mr. Trosack is recovering from was not a planned surgery so case management should have begun working on this once he was admitted to the floor postoperatively. Healthcare Issues and Their Importance

There are numerous healthcare issues that must be considered in discharge planning for Mr. Trosack to ensure that medical, social and functional issues related to his recovery have been evaluated. Safety is a very important healthcare issue that must be addressed prior to discharge. As with most patients over the age of 65, Mr. Trosack is at high risk for a fall for various reasons. 33% of this age group experience one fall per year and commonly involve falling down stairs or steps (Heasley, Buckley, Scally, Twigg, & Elliott, 2005). He lives on the second floor of an apartment building that has no elevator so he must maneuver a long flight of steps to enter or leave his apartment. In addition to this, he has a small apartment that is cluttered with WWII .memorabilia and furniture which increase his chances of tripping and falling. Mr. Trosack has recently been diagnosed with hypertension and noninsulin dependent diabetes which will present another healthcare issue and result in a lifestyle change for him. Previously, he was not taking any prescription medications and expressed displeasure about having to take the Lopressor and Glucophage now. Although he was educated and demonstrated competency in the hospital on use of a glucometer, this will necessitate a change in his daily routine and be a difficult adjustment. This may also present some challenges for him due to his vision problems. In addition to these medications, these new diagnoses will require a change in his diet to reduce his weight and the sodium and sugar he ingests. Mr. Trosack verbalized that he eats most of his meals at the bakery he owns which may present an issue with these new dietary restrictions. The addition of Lopressor also has challenges for Mr. Trosack. Lopressor may affect the blood sugar, cause blurred vision and dizziness. These side effects could exacerbate his risks for falls. Another healthcare issue to consider prior to discharging Mr. Trosack is the support system that he has. There are numerous lifestyle changes that are required due to his recent hip surgery and diagnosis of hypertension and diabetes. Changes to lifelong patterns can be difficult for the elderly to comprehend and retain and often require ongoing reinforcement. There appears to be some tension between Mr. Trosack and his son and they do not have contact on a frequent basis. Other than one brother, Mr. Trosack does not have any other support people emotionally or functionally. He currently lives alone in an upstairs apartment with no access except using stairs. Without a well established support group, activities such as cleaning, shopping, cooking and transportation will present challenges. The home assessment revealed that he keeps little food in his apartment and admitted to eating most of his meals at the bakery. This food does not support a well balanced meal which is needed to promote healing and compliance for his new dietary restrictions. His new medication regimen and use of a glucometer may be confusing and he would benefit from ongoing instructional support and reinforcement. Interdisciplinary Team Members and Their Roles

An interdisciplinary discharge planning team is vital to the success of appropriate placement for a patient. The case manager, dietician, occupational therapist, physical therapist and nurse contribute vital input from various aspects. The nurse educates the patient on the new diagnoses, medications prescribed and their side effects, administration of these medications, and the importance of adhering to these guidelines. The physical therapist begins working with a patient on the first day postoperatively. This team member instructs and assists the patient with ambulation, transferring safely, hip precautions, strengthening exercises and determination of appropriate durable medical equipment that will be needed in the home. The occupational therapist works with the patient and their family on performing the activities of daily living and instructs them on the use of the assistive devices. The dietician is important for developing and educating the patient on the importance of correct food choices to promote healing and keep their hypertension and diabetes under control. If the patient is on an anti-coagulant, the dietician will also incorporate the specific foods to avoid into their teaching. Lastly, the case manager brings all of this information together from the various team members and develops a plan based on their input. This team member will make arrangements for placement based on the assessments from the rest of the team once the discharge criteria have been met. Safety Assessment

There are several safety concerns that must be evaluated when planning the best placement for Mr. Trosack. He lives in an apartment on the second floor and must use stairs to access his apartment. He is a risk for falls due to reasons listed above in addition to recovering from recent hip replacement. There is no indication if there are handrails on these steps which would further complicate his ability to ambulate in and out of his apartment. The steps should be in good condition with full length rails on both sides. Within the apartment, there are several potential problems that would need to be addressed. The apartment is small and cluttered with furniture and memorabilia which would make it hard for him to maneuver around. The case manager performing this safety assessment should look for telephone, extension or lamp cords that could be in areas Mr. Trosack would be walking. There are also multiple scatter rugs that could easily slip or bunch up causing him to fall. These would need to have non-skid backing on the bottom of them and make sure they are not stacked on top of each other. Lighting must be evaluated to ensure that switches are easily accessible and in areas that would prevent the need to walk through the dark to turn them on. There also needs to be a lamp or switch within easy reach at the bedside. Mr. Trosack’s bathroom is small and does not have safety rails installed. The tub and shower would need non-skid surface and a grab bar installed. There are multiple expired medications in the medicine cabinet that must be destroyed and education should be performed on the importance of this processes. The kitchen is small but will accommodate ambulation with a walker. The case manager needs to ensure that items are easily accessible and do not require climbing to reach them. There should be a list of emergency numbers listed by the phone and in large print. Discharge Plan Needs

There are several items of concern related to family support that should be factored in when formulating a discharge plan for Mr. Trosack. There are only three family members available to support Mr. Trosack and none of these are in a position to offer this support consistently. Mr. Trosack’s brother is elderly and will be heavily involved in running the bakery during Mr. Trosack’s absence. This will dominate the majority of his time during the day time hours. The other family members, his son and daughter in law, both work full time jobs with an average work week of 60 hours per week. This and the stress associated with their work would make it difficult for them to physically assist Mr. Trosack in his apartment consistently. In addition to the time constraints, there have been some issues that have caused their relationship to become distant. There has been little contact between Mr. Trosack and his son even though Mr. Trosack lives alone after the recent death of his wife. This lack of support and involvement after the death of Mrs. Trosack would not lend credence to their commitment of support after his discharge from the hospital. In addition to this, they do not appear to grasp the seriousness of his newly diagnosed medical conditions and consequently, may not assist him in adhering to his diet and medication regimen. These barriers with Mr. Trosack’s brother, son and daughter in law would leave many activities of daily living unattended to if he were discharged to his apartment. Mr. Trosack would be left in his upstairs apartment without assistance in obtaining groceries and preparing meals, cleaning and disposing of garbage, or monitoring and treating his newly diagnosed diabetes and hypertension. Social Isolation and Psychological Factors

Clinical depression in the elderly is often hard to detect because of age related conditions, medications and co-morbidities and pain (Mauk, 2009). This depression can occur after life changing events such as retirement, death of a spouse, chronic illness or loss of independence. When this occurs, the patient often curtails their normal activities and decreases their social activities. This results in social isolation, increased stress and worsened depression. Mood disorders and stress have been proven to have a negative impact on healing and recovery resulting in poorer outcomes (Givens, Snaft, & Marcantonio, 2008). These negative emotions directly affect stress hormones resulting in stress-induced changes that have been proven to delay wound healing (Kiecolt-Glaser, Page, Marucha, MacCallum, & Glaser, 1998). Mr. Trasock has several factors that would put him in this category. His recent loss of his wife, estranged relationship with his son, hospitalization, diagnosis of chronic medical conditions and potential isolation of becoming temporarily homebound or admitted to a rehab facility. In addition to this, he is at an increased risk for falls and has verbalized concern about ambulating up and down the stairs to his apartment. This fear can result in reduced mobility, less socialization and independence which may perpetuate the depression and isolation. If Mr. Trosack were to remain alone in his apartment all of the time, he is at risk for becoming disoriented with time. This could affect his compliance with medication administration, regular meal preparation, physical therapy and thus decrease his potential for a successful outcome. As discussed in Wichowski & Kubsch, 1997, “Low self-esteem or poor psychosocial adjustment can influence functioning, the degree of participation in rehabilitation and exercise programmes as well as acceptance of disability” (Chau, Martin, Thompson, Chang, & Woo, 2006, p. 49). Recommendation

Whenever possible, the ideal outcome is to place the patient back into their home if at all possible. Based on the safety assessment, family and patient interviews, support system and new onset of diabetes and hypertension, Mr. Trosack’s home does not present as the best option for him unless there were several changes that were made. Mr. Trosack’s family states that he is capable of taking care of himself with their help but they are probably unaware of the extent of his needs. The case manager might suggest that the family come to the hospital for a day and work with Mr. Trosack on this therapy, ADLs and monitoring of his glucose. At this time, they could develop a concrete plan for meal preparation, grocery shopping, household chores and transportation and determine the amount of time this would involve. They would probably better understand that his is not able to independently care for himself and the amount of time that would be required of them. If he is adamant that he is not going into a rehab facility or assisted living facility, the case manager might inquire about him temporarily going to the brother’s house. This would keep him loosely connected to the bakery and in close contact with the family member he is more involved with. To do this, Mr. Trosack would have to make some concessions and allow home health services to come in. Home health services would relieve some of the pressure as far as dressing changes, physical therapy and nursing to assist with monitoring his diabetes and hypertension. They also would be able to assist in arranging for some community support like “Meals on Wheels” to deliver at least one hot, well balanced meal daily. Additional sitters could be hired to supplement the time that the family is unavailable. A safety assessment would have to be performed and possible minor changes made to accommodate him in his brother’s home. If the family is not able to assist in this capacity, the better option would be to admit Mr. Trosack to an assisted living facility until he is more independent. This would provide him full time assistance and the opportunity to socialize with other residents and activities to avoid social isolation. Once he has regained his mobility and is managing his diabetes and hypertension well, the team could re-evaluate the possibility of him returning to his apartment.

References
Chau, J., Martin, C. R., Thompson, D. R., Chang, A. M., & Woo, J. (2006, February). Factor structure of the Chinese version of the Geriatric Depression Scale. Psychology, Health & Medicine, 11(1), 48-59. Retrieved from http://ehis.ebscohost.com.wguproxy.egloballibrary.com/ehost/pdfviewer/pdfviewer?vid=9&hid=124&sid=10babee4-c2f0-48a0-8204-ba1b2087ee4e%40sessionmgr110 Givens, J. L., Snaft, T. B., & Marcantonio, E. R. (2008, April 18). Functional recovery after hip fracture: the combined effects of depressive symptoms, cognitive impairment, and delirium. Journal of the American Geriatrics Society, 56, 1075-1079. doi:10.1111/j.1532-5415.2008.01711.x Heasley, K., Buckley, J., Scally, A., Twigg, P., & Elliott, D. (2005, October ). Falls in older people: Effects of age and blurring vision on the dynamics of stepping. Investigative Ophthalmology & Visual Science, 46, 3584-3588. doi:10.1167 Kiecolt-Glaser, J. K., Page, G. G., Marucha, P. T., MacCallum, R. C., & Glaser, R. (1998, November). Psychological influences on surgical recovery. Perspectives from psychoneuroimmunology. American