Outcomes.  This is a word that has been re-defined and foisted upon the healthcare community as a measurement tool in connection with reimbursement, liability, marketing, competitive viability, software decision making, patient screening, to name only a few terms, that we seldom if ever thought about when preparing to become actual healthcare practitioners. 

As students and bright eyed new doctors, therapists, nurses, or healthcare managers, we first thought of patient outcomes in terms of how well the individual patient was doing…. without having to drill down to statistical analysis or secondary concerns. 

Now, our risk managers, marketing directors, insurance companies, financial directors and everyone up and down the food chain thinks of outcomes in NON-individual statistical measurements of some kind, depending upon their specialty.  To achieve any outcome, however, we must still start at the beginning, the patient and the patient’s support system.  And, for many of us, that is somewhat of a relief….

Returning to the original idea of outcome, I would like to come back to the patient, more specifically, the patient’s family, and point out that one significant and frequently overlooked source of improved outcome is the human component of the caregiver.  Nowhere is this component more relevant to outcome than in the geriatric and empty nest community of patients. 

I have deliberately titled this article “She” is not your patient, because of the statistical frequency in which the wife is the primary caregiver of elderly men.   -- And, not only elderly men and husbands, but elderly sisters, companions and friends.   Indeed, among the elderly, the actual caregiving burden falls to females the vast majority of the time—to wives, daughters, sisters, and daughters in law. 

To call this a weak link in managing outcomes is decidedly unfair; these determined women are often the best chance for clinical follow-through and a good outcome.  However, the actual resources and capabilities of these women are widely varied and often limited.  Recognizing and addressing the caregiver’s strengths and limitations before a surgical, pharmaceutical or therapeutic intervention is key to managing and achieving the desired medical outcome for your patient.

A primary problem in addressing this barrier to good outcomes is the lack of self-recognition by the caregiver or the patient, or actual resistance to admitting they have limitations at all for fear of losing freedom or being perceived as feeble or incompetent.  Coping strategies to mask or cover changes in memory, problem solving, physical ability or mental status are often, unfortunately, very effective, making it difficult to spot in a typical cursory visit.  This is particularly true when the “cover-up” is the graceful result of a joint effort by a long-term couple.

It is critical to have the caregiver repeat instructions back, both immediately after providing the instructions, and again, prior to leaving.  Asking if she has any questions is not sufficient, nor is providing a written instruction sheet, though of course, this must be done.  If she is unable to adequately verbally understand and repeat the instructions, the odds are great she will have difficulty accessing the information on the instruction sheet and/or remembering to use it. Socially appropriate, well educated and well groomed clients often have excellent masking skills, but cannot pass this test.

Recognizing the physical limitations of the caregiver, if she is to provide physical assistance, is also a significant and often overlooked aspect of patient care.  The preponderance of osteoporosis and cardiac issues among elderly women, considering the high number of older women providing physical care, is significant.  Caregiving can include high-risk activities of bathing, transferring, grooming, dressing and other labor intensive tasks, as well as remembering medications, exercise, toileting schedules and other needs.  Today, this duty may also be combined with caring for a relative’s children or raising grandchildren, resulting in time limitations in addition to the aforementioned issues.  

The physical ability to accomplish care-giving tasks, and the ability to accomplish them without risking very real physical and emotional injury may place your actual patient’s outcome at risk.  Asking about other family members, neighbors and alternative resources initially may help to achieve a better outcome.  Determining the realistic home situation of the patient, the caregiver’s physical and cognitive ability, and the actual resources available to the individual prior to treatment, will help promote a better outcome.  

Home health, direct contact and education of family and friends that will be participating in after-care, a temporary in-patient rehabilitation stay in a Skilled Nursing Facility with a good therapy program or in-patient hospital are also excellent transitions and vital steps to maximize outcomes and to further assess caregiver and patient abilities.  The woman accompanying your patient is not your patient, but knowing her as if she were, may determine your patient’s outcome.

CeCe Todd is President of LifeSpring Therapy Solutions, LLC, a company that provides in-patient rehabilitation, (Physical Therapy, Occupational Therapy, and Speech Language Pathology,) services for Skilled Nursing Facilities throughout Arkansas.  CeCe also provides consulting and education services on a wide range of topics ranging from Medicare management, reimbursement, and patient care issues related to SNFs, to fall management, communication and home safety, for community groups.

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