Tough Questions: “Do we continue our CCM system with Dementia Patients?”

To continue our series of “Tough Questions” we created a situation with a theoretical patient in which posed us with the ethical dilemma of determining whether the patient was going to be able to continue with their chronic care management program. This patient had exhibited numerous signs of dementia in the past. Our nurse had noticed that this patient’s dementia was worsening every time she spoke with the patient. In this scenario, the patient’s dementia had progressed to the point where they were no longer oriented to their location. Having recently been moved by the family into an assisted living facility, the patient did not understand where they were and only knew that they had been moved somewhere. They were not able to tell us the name of the new facility or when they had moved. As a result, our nurse had to continually remind the patient of who they were, why she was calling them, and the reason behind the call.

This patient could have been having a bad day; after all, with dementia and Alzheimer’s patients, that is a regular occurrence.  However, it continued to happen after two additional phone calls to check up on this patient. It’s at this point we would have made this information known to the physician, as this was a clinical decision that needed to be made by the primary care provider.  After a theoretical thorough discussion with the physician, the best plan was to contact the patient’s medical power of attorney and determine if they felt that the services continued to be needed. (This may not be the case for all dementia patients.)

Here is where things can get questionable: if you run into a situation like this where the patient should be in the program prior to this point, you have to ensure that the medical power of attorney is agreeable to receiving calls from your team, with the understanding that you will not call and speak with the patient directly any longer. In a case like this, you might have to redirect all calls to the medical power of attorney, and they would then have to fulfill the requirements that you design for making sure that the patient’s care plan was updated with the most accurate medical information. If we were taking care of a patient like this of course, our nurses would continue to call on the patient just to check up on the patient’s personal feelings regarding their health, but all of the core information would come from and go to the medical power of attorney.  

This is very important because, without the permission of the medical power of attorney, you could be getting into a legal situation that you do not want to be in. This is something that needs to be completely clarified with the MPA and with the physician when dealing with medical dementia patients or Alzheimer’s patients. This is one of the reasons why it is so incredibly important for chronic care management nurses to have a clear comprehensive care plan from the doctor, a clear plan of action established and implemented for each patient and their individual needs.  It is pertinent that this is established in order to give the best care for the patient, but it is also important that the nurse or staff running the chronic care management program has a clear understanding of what has been discussed during face to face interactions with the patient.  

In a case like this another very important observation to note was that clearly, any family member would have known that their loved one was getting worse as they were moved in to the assisted living facility. However, without regular contact from a care nurse, the primary physician would have had no idea what was going on until the patient returned for a follow-up visit.  What if the patient’s next visit was in six months or a year? There could have been some very important medical occurrences of which the physician would have no idea. At the end of the day, the more information that you arm physicians with, the better they are able to understand, and the better they are able to diagnose and give patients exactly what they are needing in order to provide the best patient care.  This is very important for physicians. The continual contact that these nurses have is one of the most vital resources that contribute to a successful chronic care management program.  

Basically, a chronic care management program gives physicians the best way to have weekly or monthly interactions with patients in order to ensure that the patients are getting the absolute best care possible.  It keeps physicians informed with the best and most current details regarding their patient’s mental health, wellness, and overall well-being. When physicians are kept informed, it allows both the physicians and their patients to make better decisions, to make healthier decisions, and to make sure that the patients’ medical needs are at the forefront of their health care.  In turn, this provides a closer relationship between the patients and their doctors. When patients have this kind of access to their doctors, and when they are able to get their information processed and prescriptions were taken care of, and they know they can share their revelations to their doctors, it creates a stronger trust with that doctor. This bond is made possible through our chronic care management nurses.  They are the ones on the battle line getting the information, nurturing in-depth relationships with their patients, and earning the patient’s trust. Through this process, the patients build trust that their nurses truly and honestly care about what is going on in the patient’s lives.  

This is what sets us apart from other chronic care management programs.  Not only have we built a CCM solution that is able to bill out a CPT code that returns a profit, but we are truly and honestly building physicians’ practices so that they have a deeper understanding of what is happening with their patients.  This, in turn, allows the patients to experience a stronger bond and have more trust with their physicians. This kind of trust between physicians, patients, and nurses can literally mean the difference between life and death with many patients.  You must keep in mind that these patients are chronic care managed patients and have conditions that could potentially lead to death, or a prolonged situation in which the disease that they have is not going to get better and is only going to get worse.   

The best way to ensure that patients live longer and healthier is to ensure that the exchange of information between nurses, patients and doctors is strengthened on a monthly basis.  The services we provide are invaluable to both physicians and patients. These services absolutely change the lives of patients. For physicians, it strengthens their practices and helps them reach the goals that they have been seeking to reach.

If you are looking to strengthen the exchange of information between your team and the patients you serve we are here to help you develop a system to accomplish your goals. Call us today at (806) 798-1344 or email us at [email protected] more information on Chronic Care Management contact Bryan Rose [email protected] 806-543-1435 or Lindsey May [email protected]

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