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Member of the care team contradicted each other. Many areas of the care team were not represented. Nobody was in charge. They couldn't answer our questions. Nobody took any action items to research, investigate, and report on any of the issues. The tone of the meeting was CYA and blame the departments that did not attend. The family now has the burden of doing the research, follow up, and coordination of the various disciplines involved in the care and treatment. We are new to this. Is this typical and the level of professionalism we should expect? Can anybody provide a short tutorial of how these teams should function?

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I'm assuming this was the required every 60 - 90 day "care plan meeting" at a NH, correct?

This should be scheduled in writing and at the meeting either someone from activity, dietary, nursing and social services or they send in their report. My experience is that only in rare situation is the NH medical director or the DON
(director of nursing - who is the god or goddess of rulers @ the NH) ever there.
You should be asked to sign off a sheet that either states the status or concerns the staff has for your mom and it is in the form that you can write in your concerns.
This is very important for you to do this and understand that you have to do this, otherwise you have no issues with their care plan.

If this was your first, then I'd send a fax to the attention of the DON (not a phone call, this need to be in writing and a fax is good as it establishes they got it), that you have some concerns regarding your mom's care and would like to schedule a meeting with her (the DON) and someone from her nursing staff at their earliest conveience. I've found the administrator is not the one to go to on this - the adminstrator is all about dealing with fed & state compliance stuff. Now if you do this, you really need to have a written page of specifics you either need addressed or have questions about. This is a business meeting and you want to stay on track and not get all emotional. By doing a list in advance and in writing, this helps keep you on track. You want to make sure the list get's placed within her medical chart @ the NH. So bring a couple of extra copies to the meeting and state on the bottom: "This page to be added to the medical chart of Anne Smith, resident of Happy Trails NH & Rehab, as per Jane Jones, DPOA and MPOA for Anne Smith, with the date.

If you have the gut feeling they won't do it, then you fax it over along with your thank you for meeting with me note to the DON.

I had some issues with the weekend wound care team at my mom's NH which were glossed over at the care plan meeting because the weekend workers were not there to provide input. I sent over a fax along with a couple of photos of how the weekend bandages were done and the status of her socks and presto, the DON sent me a letter within a week that the procedure would be monitored by the floor RN and a update wound care guideline was done for my mom. Just keep whatever as simple and specific as possible. Good luck.
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Thank you igloo572. Your insights are very helpful. One thing that struck me during our meeting is that nobody from the NH staff took the role of patient advocate and / or service coordinator. Although the Social Services Coordinator participated in the meeting, her role seemed to be to promote good PR for the facility. She did nothing to coordinate services from the multiple disciplines. Am I hoping for too much by expecting them to provide actual coordination of services?

Also, yes they did pass around a sheet for us to sign. This happened as discussions were in progress and it seemed to be merely a list of attendees. It was never explained that this was our affirmation of their care plan nor did we actually look at it that closely (out of respect to paying attention to the ongoing discussion). Shame on us for not realizing what was happening, but live and learn and now we know.
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foe - you really have to be the patient's advocate. Staff changes often and just when you find the one in synch with you, they get a better job or retire. As far as "co-ordination of services" that seems to be let up to the DON as how it's done. My mom has been in 2 NH and the old one had a MSW as the "co-ordinator" and she was fine but really the DON ruled, the med director was there usually on a glide through to see residents. This NH was the type that sent the resident to the hospital rather than stay in NH. The new NH does have a MSW on full time staff but she is not the co-ordinator between pt family and facility, this one has it as the associate DON who does this. I will say this NH (#2) has it such the the medical director has 2 NP's who are there twice a week and they also have medical students and interns there often. Medical director is much more hands on at this one and they do not do an hospital admit as the first response. When they get ill, they usually go to first floor rehab wing for a short stay to see before any hospital transfer. These are the sort of things I never thought about could be so important and a huge difference in approach to care.

Did you discuss advance directives before they went into the NH? Does she have one on file? Any discussion on this?
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I don't know what is typical, but your experience sounds a lot like ours. One of us got a call asking why no family members attended the care meeting, especially since our mother was so close to discharge. Meeting? We were never notified of a meeting. When was it? "Oh, tee-hee, it does look like no one contacted you, tee-hee. We'll schedule another meeting." Four of us showed up to hear about the care plan for our mother for her broken arm. No one seemed in charge. It was disorganized. The physical therapist couldn't answer a question about Mom's prognosis. (Later my sister said it was clear she didn't know the meaning of prognosis.) They advised us that Mom shouldn't continue to live alone. But guess what the good news was? They happened to have an opening in their nursing home wing. It was a lovely building but among us we had no trouble agreeing that when Mom did need a nursing home it wouldn't be this one!

I'll be interested to here is this is really "typical."
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foe & jeanne: Typical? Yes, unfortunately in too many of them. But not all. You have to do your homework. Show up often & at different times of the day, even late at night. Make your presence known with the staff. Staff may not like you & consider you to be a PIA, - but mom will be better cared for. Make notes to keep records, initial dressings so you know when they've been changed. You can even mark bed sheets to know when they've been changed. You have to do your homework.
Staff is overworked & underpaid; turnover of staff at many places is horrendous. At some places you can be the senior person on staff within 3 months! It also helps to try to build good repoirre with the staff - if you can afford it, bring a box of donuts or cookies to the Nurses' Desk (dont forget the other shifts). Be sure to express appreciation to the ones who you find do a good job & go the extra steps in caring for mom. Also be sure to let the supervisors know who is going the extra mile, so to speak. -Been there, done that (have worked in NH's for way too many years).
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Oh my, I can sympathize with you. My mother was in rehab with a near fatal brain injury last summer. The facility had rehab, AL, NH. This was our first experience with serious injury. She had a social worker and case manager assigned to her. The first (and only) care meeting was a joke. My sibs and I took the day off from work. Some traveled a distance. No one who represented the rehab was prepared. It was so bad I honestly thought they had the wrong patient's info. It didn't even sound like they knew who my mom was. I had to do breathing exercises to keep my cool. The social worker looked like Snookie from Jersey Shore.

The meeting began by everyone introducing themselves, then the caseworker stared at us and said "Have you decided what you want to do? She's not gonna get better so have you looked into where you want her to go?"

We were speechless. Needless to say, the relationship between us tanked from there. The caseworker wouldn't even return my calls. When they discharged her, they wouldn't even schedule an exit interview. I had to find the nurse, PT, OT on my own for instructions.

We, too, decided that my mother, and no one else from our family, would ever enter that facility again. Luckily, we found a good in-home care agency that has been tireless helping us with our mom.

So, I guess it's more common than I knew. Pathetic.
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My experience: typical! At our meetings for my mother, they had a lot of people there who seemed to know only their names and job titles and nothing about my mother or her treatment plan. And they seemed only to have been organized enough to draw up the treatment plan, but not enough to execute it. My mother, who had broken her pelvis, was supposed to have physical therapy every day. There was always some reason why it was called off. It took two weeks for them to bring her a toothbrush. She wasn't supposed to have pork or beef, yet her meals always included both--and pepper, for which a warning in bold red letters covered her chart--so she simply stopped eating. They took her off all the blood pressure meds she'd been on for years, and put her on new ones, which included one that gave her a persistent cough. (We learned this only when she finally went to see her own doctor months later, and she pointed out the side effect of the NH-prescribed medicine was a cough.) The amount of money that went to the church that runs this nursing-home factory was astonishing, given how terrible it was.
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Real interdisciplinary care requires communication and steering, not just each profession giving a status report, but there are any number of barriers to that happening. We have conferences with families that are structured but with the team physician in charge - and over the years the team has gotten comfortable the the level of give and take that you need to make it work. And there has to be decent ongoing communication as well. That is not meant to be an excuse for bad care, or the fact that someone who cares, usually a family member when an organization is so cutlurally comfortable with delivering bad (uncoordinated, cookie-cutter, careless, unthoughtful) "care" is in the picture, has to force the system to work to the benefit of each individual - if they can. I wish there was an easy way to change this, and overcome the barriers to doing it right. In an immediate practical sense, probably the best you will do is to find a sympathetic liasion on the care team who will actually communicate and work with you, and use the ombudsman or grievance procedure selectively but assertively if you must.
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And, though you would think bribery would be too transparent to indulge in, or that team members would be averse to it in some way, you would generally be wrong.
Bring on the chocolates and cookies; sadly, it tends to work.
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I want to say that I don't think that my mother was getting poor care in her rehab place. And the staff seemed friendly and upbeat. But the total disorganization of the care team meeting and the self-promotion of their nursing home really turned all of us off.

The adult day health program my husband was enrolled in also was required to hold care conferences every 90 days. They generally consisted of a social worker, a nurse, and one other staff member. All people involved knew my husband well and could speak about any issues he was having. They included him in the conversation and never spoke as if he wasn't in the room. These were typically short meetings and were run very professionally and efficiently while at the same time were very personable. They could have given lessons to the rehab center in how to run a care conference, and probably how to really function as an interdisciplinary team.
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Sorry to hear of your problem with this. My own experience for my Mother was just the opposite. She was in a local home, small town--our hometown. Staff were people known to us for the most part. They run a tight ship. I attended every meeting for over five years, with my brother attending the first few as well. There was a representative from department heads, and the DON was just down the hall---the DON was known well to me and I visited her often on my own with any health concerns for my Mother. She was always approachable. I found in my meetings that each department would go over the care plan and ask me if I had any concerns or issues. They were always very willing to accomodate my Mother in any area where an adjustment needed to be made. My Mother was not mentally able to attend and insert her input, but they (department heads) visited her almost daily and knew her needs and condition. It was always a pleasant experience for my brother and me. She passed on in January due to parkinson's and other health conditions. She was just short of 91.
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I have been to several of them, and I have to say that I've been satisfied with the outcome. They went over everything with us - her progress in physical therapy, her medications, appetite, etc. etc. They asked my Mom if she had any concerns or complaints (which she always does, about the food...haha), or if we had the same. My biggest problem is that I always forget to write down what questions I want to ask ahead of time & then forget them once I'm there...but that's on me, not them.
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