Patient: Mr. Charlie Breather
Case Manager: Ms. Holly Carewell, RN, CCM
Facility: Panhandle Regional Medical Center
Reason for Referral:
Assess psychosocial factors impacting Mr. Breather's recovery from pneumonia and COPD exacerbation.
Address concerns related to adherence to prescribed treatments and patient education needs.
Patient Background:
Age: 65 years old
Living Situation: Resides alone; daughter serves as primary caregiver and healthcare proxy.
Support System: Limited social support outside of his daughter, who is very involved in his care.
Occupation: Retired; previously worked as a carpenter.
Financial Status: Fixed income; some concerns noted about medication affordability if prescribed beyond insurance coverage.
Mental Health & Coping:
Mental Status: Alert, oriented, and able to make decisions about his care.
Emotional State: Displays signs of anxiety related to his illness and the effects of medications (particularly the bronchodilator which makes him feel shaky).
Coping Mechanisms: Reluctance to use bronchodilators due to side effects; attempts to control symptoms by limiting activity rather than adhering to prescribed treatment.
Motivation: Mixed; desires to improve breathing but feels overwhelmed by treatment requirements.
Family Dynamics:
Daughter: Assertive and well-meaning, but her insistence on strict adherence to treatment protocols creates tension between her and Mr. Breather.
Healthcare Proxy Status: Mr. Breather has not formally revoked his daughter's authority as his proxy but maintains decision-making capacity.
Barriers to Care:
Medication Adherence: Hesitancy to use bronchodilator due to unpleasant side effects.
Understanding of Condition: Limited understanding of how medication and activity level affect respiratory function.
Financial Concerns: Potential difficulty affording medications if coverage is inadequate.
Emotional Support: Limited support outside of his daughter, which may contribute to his reluctance to pursue optimal care.
Recommendations:
Education: Provide education on the importance of medication adherence and explain potential side effects versus benefits.
Care Coordination: Collaborate with the healthcare team to address Mr. Breather’s concerns and explore alternatives to current bronchodilator treatment.
Support Resources: Recommend referral to a pulmonary rehabilitation program and social work consultation for financial assistance resources if needed.
Family Counseling: Facilitate communication between Mr. Breather and his daughter to ensure shared decision-making and understanding of his wishes.
Follow-up: Schedule a case management follow-up within one week to reassess adherence and address ongoing concerns.