Use of the Shared Care Plan over time: One patient's experience.
Last August, 2002, I was referred a delightful patient with heart failure. Betty (her real name by her permission) is a bright motivated and alert person of now 89 years' wisdom. She had had two hospital admissions in August and her cardiologist felt she was a perfect candidate for the Pursuing Perfection project. She had recently moved to Bellingham to be nearer her family since she had begun to have more serious medical problems. She was already active on the Internet and continued to contact old friends through email. ( "I asked the young man who was installing my modem: "If I'm learning to email at age 88, what do you think you'll be learning at that age?" He said, wonderingly, "I cannot imagine!")
So we began our relationship and developed the Shared Care Plan together. She was delighted to have a single medication list. She had actually been using her most recent discharge medications list which had all her cardiac meds but did not include all the other medications she'd been prescribed from her PCP and GI specialists. I coordinated her appointment with her new PCP at the Center for Senior Health. Dr. M. was more than pleased to interview her the first day and already have a complete and verified meds list on the SCP. Betty became more knowledgeable about the use of diuretics, why she was logging her weight, and who to call when she had a problem. She repeatedly said how wonderful it was that she could call me to clarify something when she needed to.
She stabilized and reported to me happily that she was going to Arizona for the winter months but would keep in touch. She proudly presented her SCP to her cardiologist and gastroenterologist in Arizona. They too were impressed and pleased to have all her pertinent information in a single place. Betty sent occasional emails and was having a wonderful time. Regrettably, in January 2003, while still in Arizona, things took a turn for the worse. She suffered a severe GI bleed and was hospitalized for several days. When she returned home, she was shocked to find her weight well above the target of 112. She immediately took some Lasix and contacted her cardiologist since she knew she was at high risk for developing shortness of breath from her CHF. She also emailed me in Bellingham to let me know what had happened and to ask advice for how she should proceed. I cautioned her to not be impatient since she was so fatigued after that episode. I warned her about the potential for orthostatic hypotension and encouraged her to not overdo too soon. Just a few days later I received another email from her daughter. Betty had fallen and fractured her hip. She had pins placed and was able to fly back to Bellingham several days later.
Once back, she contacted me again and we quickly updated her SCP. Her local physicians have continued to use it as have her daughters.
The SCP was a valuable tool first for Betty. She relied on it for accurate information. She always took her copy with her whenever she had a medical appointment.
It was equally valuable for her physicians while she was in Arizona as well as when she is at home in Bellingham. Her original PCP in Alaska actually has gone online and could see what has progressed as well.
The SCP is a wonderful tool that helps the patient, her family, and her clinical providers all to understand what is happening in the moment. Use of it promotes improved communication about what is important to the patient personally and relieves some of the burden of having to repeat to multiple individuals her history and what meds she is on and why. Improved communication leads to greater safety for the patient and a higher level of satisfaction for all concerned.
