As nurse case managers and patient advocates, we discuss engaging our patients in their care. I recently had an experience that showed me how powerful patient engagement can be.

Friends of mine have a sister who lives in Arizona. Their sister, Nancy, recently lost her husband after a long period of illness. She is sad as she mourns his loss. Nancy was her husband’s advocate and experienced many of the issues caregivers and patients go through during an illness. It took its toll – but she is a positive person working to find her way as she moves forward.

In conversations with my friends, I learned that Nancy needed a Total Knee Replacement. This had been expected, but due to her husband’s illness and death, she had postponed it. As she was having more and more pain and trouble walking, she told her sisters (who live in another state) that she was going to talk to her orthopedic doctor about getting the knee replacement done. She asked for their help, and both agreed to help as best they could.

They set a date for December 12th. Nancy and her sisters are planners, so they got to work making plans for what they would all need to do over the next few months. As they considered what needed to be done, they realized they needed help. They asked me to help coordinate care and find resources she might need post-operatively.

As I did not know the resources in Arizona, I talked to a case management friend who lived there. Although she was retired, she said she would be willing to help my friends as she knew the hospitals, rehab programs, and home care organizations that would be needed. I introduced them, and we met on a few calls to discuss the process and plan of care for Nancy.

Nancy learned where the procedure would be performed. We called the case management department at the designated facility to understand better the surgical side of the procedure and how things were handled afterward.

An excellent care coordinator took our call, listened to the situation, and gave us some suggestions. One of Nancy’s major concerns was how she would manage after the procedure, as she lived alone. Based on her experience, the care coordinator gave us some ideas. Nancy and her sisters were going to check out the recommended rehab programs to see what would work best, but until the procedure happened, we would not know what she would need in terms of post-op care.

As the procedure approached, the plan came together. The sisters flew to Arizona to help Nancy get to the hospital. They planned to stay until Nancy had the surgery and was safe in the rehab unit.

In a conversation with the hospital’s care coordinator and the case manager from Arizona, they explained that deciding what to do post-op would depend on Nancy’s condition after the surgery. Today, many post-op Total Knee Replacements go home but with support from family and home care. This would not work in Nancy’s case, as she was alone, but there was little we could do before the surgery. Nancy made some tentative arrangements ‘just in case.’

Another challenge we learned is that Medicare requires a three-day stay to pay for the Rehab admission. The Care Coordinator did not know if Nancy would meet the criteria for the three days until they saw how she did post-op. This added to the level of anxiety as the date for the surgery approached.

As things turned out, the surgery went well; the sisters were a huge help in supporting their sister before and after the surgery. She was able to qualify for the three-day stay required due to her past medical history and issues that arose during the post-op period. Nancy went to a skilled care rehab program she and her sisters checked out before going to the hospital. The facility was clean and modern, but most importantly, it could meet her needs. The staff was caring and supportive and ‘got Nancy moving.’ Nancy is now in her own home and doing well. Here is some advice Nancy asked me to share to help others!

Knee Replacement—Been There, Done That by Nancy Edelstein

It IS doable. You CAN get through it! YOU CAN DO IT!!!

Yes, it’s painful and challenging, and PT is crucial and painful. But you’ll see significant progress daily. And time will pass quickly until suddenly, you’re 2 weeks post-op…3 weeks post-op, and on and on. Some tips & hints:

* There will be good days and bad days—take it a day at a time.

* Ice it—A LOT!! Buy a Breg Polar Cube.

* Pain meds are necessary. Do NOT stop them too soon. But as you progress, maybe cut back before and after PT and at night to sleep.

* Engage the help of a nurse advocate!!!

I was proud to work with Nancy and her sisters to help them through a difficult time. Nancy knew what she needed, and she pushed us all to ensure her needs were met.

This story exemplifies patient engagement—working with patients and their families to meet their needs and access the needed resources. As a result, she had a positive outcome!

Please share this post with your family, friends, and colleagues so they can see the importance of patient engagement in improving their healthcare experience.

Have a good week!

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