by Paula Erwin-Toth MSN, RN, CWOCN, CNS

Part 3 in a series discussing the challenges and opportunities in patient/family education
For Part 1, Click Here
For Part 2, Click Here

In last month’s blog, we explored Mr. Gillian’s discharge plan and discussed the members of his interdisciplinary wound care team. Here we are seeing Mr. Gillan in his home. To refresh your memory, Mr. Gillan is a 72 year old man with venous insufficiency. He presents with a venous ulcer on his left lower leg. He has several co-morbid conditions including hypertension, cataracts, and osteoarthritis which includes his hands. His primary caregiver is his 74 year old wife who suffers from diabetes and mild dementia.

The Home Health nurse has completed OASIS on admission. OASIS is a group of data items the nurse has to document when ‘opening the case’ in the patient’s home. The Center for Medicare and Medicaid Services developed and requires completion to identify patient needs, risk factors and provides the basis for outcome measurement and performance improvement. Needless to say, opening this case took a considerable amount of time. The nurse needs to be thorough and precise—this is something every Home Health nurse (and their agency) takes very seriously. Not only does OASIS provide the basis for the patient’s care and determines needed services, it serves as the basis for reimbursement.

Despite the wonderful support the Gillian’s are receiving from their church group including meals and transportation to physician’s visits, Mr. Gillan’s home health needs are still significant. In addition to skilled nursing care he needs physical therapy, a home health aide, social work and a dietician. This is a “tough row to hoe” for Mr. Gillan. He has always been independent and worked hard to keep his wife safe and well. In fact, Mr. Gillan was so focused on his wife’s needs that he neglected his own until his venous ulcer appeared. The nurse is concerned that depression is contributing to Mr. Gillan’s lack of appetite; Mrs. Gillan knows something is amiss and she has been more agitated and confused since his return home. As we know, caring for the caregiver is a real challenge. We do not care for a wound—we care for the person who has a wound. In the home environment we see how the patient lives and what their needs are now and in the foreseeable future.

Join me next month as we continue to follow Mr. Gillian in his home care environment.

About The Author
Paula Erwin-Toth has over 30 years of experience in wound, ostomy and continence care. She is a well-known author, lecturer and patient advocate who is dedicated to improving the care of people with wounds, ostomies and incontinence in the US and abroad.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.