Access to Care: Older, Developmentally Delayed Patient With Several Chronic Illnesses and New Onset of Perceived Hearing Loss
Ms. Renee Sharrod is 65 years old and developmentally delayed. Ms. Sharrod has always been considered high functioning although she is unable to read or write. In the past, Ms. Sharrod was able to respond to straightforward questions and follow direct instructions. However, as she has gotten older, she has developed hearing and speech difficulties as well as some mild cognitive decline. When Ms. Sharrod’s mother passed away, Ms. Sharrod no longer had a direct caregiver to assist her with activities of daily living (ADLs) or with healthcare concerns. Shortly following the death of Ms. Sharrod’s mother, Ms. Sharrod was moved into an apartment in an assisted-living facility.
The assisted-living facility does a marginal job of supporting Ms. Sharrod’s ADLs, such as providing meals, assisting with bathing, and administering medications. However, when it comes to managing and facilitating treatment for Ms. Sharrod’s many chronic health conditions, the facility falls short. The assisted living facility does not have well-trained or adequate caregiving staff to stay on top of healthcare visits, procedures, or equipment orders. Although Ms. Sharrod has adequate health insurance, she has no one to assist her with navigating the “red tape” involved, such as prior authorizations, and with understanding when and where she can seek services and how often. Additionally, Ms. Sharrod needs assistance with scheduling appointments, arranging transportation, and communicating with healthcare providers.
As mentioned previously, Ms. Sharrod has developed what is perceived as hearing loss. Ms. Sharrod’s caseworker schedules an appointment for Ms. Sharrod to have her hearing checked. The assisted-living facility arranges the visit and sends an aide with Ms. Sharrod to the visit. Ms. Sharrod’s hearing is evaluated at this visit, and it is determined that she has moderate hearing loss and needs hearing aids. Although this same healthcare facility also provides hearing aids, Ms. Sharrod’s insurance will not cover the hearing aids from this healthcare facility; she can only receive hearing aids from a select few places. Ms. Sharrod goes home with an order for hearing aids but needs another appointment at a separate facility to be fitted for them. A few months go by, with the overworked caseworker attempting to find out from the insurance company where Ms. Sharrod can go to be fitted for hearing aids. Prior authorization is submitted and is finally obtained from Ms. Sharrod’s insurance company. At this point, Ms. Sharrod is assigned a new caseworker, who is unaware of the prior authorization and the need to schedule an appointment to have Ms. Sharrod fitted for hearing aids, so several more weeks go by. Once Ms. Sharrod is finally scheduled and goes to be fitted for the hearing aids, she is informed that the hearing evaluation and order for hearing aids have expired. She now needs a new hearing evaluation and an order for hearing aids. Although this current facility can perform hearing evaluations, Ms. Sharrod’s insurance will not cover testing at this facility, only the hearing aids. Ms. Sharrod now needs another hearing test at yet another facility, essentially starting all over again.
This entire process has taken more than 9 months, and Ms. Sharrod still does not have hearing aids or any one person available to her to facilitate and connect the various steps it takes to use her health insurance and access appropriate care. COVID-19 emerges about 2 months later and all efforts cease; there are not enough staff to address Ms. Sharrod’s hearing loss issues. It has now been almost 2 years and Ms. Sharrod still does not have hearing aids; by all accounts, her hearing has gotten significantly worse. Her speech is now being impacted by the hearing deficit. Of note, hearing loss is only one of Ms. Sharrod’s health issues, which include diabetes, hypertension, and pulmonary hypertension. Although Ms. Sharrod has what would be considered adequate health insurance, her being older, developmentally delayed, and lacking a caregiver or advocate to coordinate her care means that she ultimately does not have adequate access to healthcare.
Case Study Questions
- What other barriers might older persons or persons with disabilities face when trying to access healthcare?
- What are steps you could take, both as an individual nurse and at the systems level, to improve access to care for older or developmentally delayed patients?
- What could be done in situations where a lack of advocacy resources and “red tape” restrict needed healthcare access?
- Develop a policy that health professionals could create and implement to address the needs of individuals in assisted living facilities. Provide a rationale for your proposed policy.
Full Answer Section
2. Fragmented and Inadequate Care Systems: Ms. Sharrod's experience with the hearing aid saga exposes the fragmentation of healthcare services. Insurance limitations dictated where she could obtain services, creating delays and restarts. Additionally, the lack of communication and continuity between care providers further exacerbated the problem.
3. Cognitive and Communication Difficulties: Ms. Sharrod's developmental delay and hearing loss further impeded her ability to actively participate in her care, understand instructions, and navigate the complexities of the healthcare system. This emphasizes the need for accessible communication methods and support for individuals with communication disabilities.
4. Ageism and Implicit Bias: Ageism and unconscious bias against individuals with developmental disabilities can lead to assumptions about their capabilities and neglect of their needs. This can result in inadequate care and missed opportunities for intervention.
5. Insufficient Resources and Workforce Shortages: The overwhelmed caseworker and overworked staff at the assisted-living facility highlight the broader issue of resource limitations and workforce shortages in healthcare. These realities often disproportionately impact vulnerable populations like Ms. Sharrod.
Steps to Improve Access to Care:
Individual Nurse Actions:
- Patient advocacy: Nurses can act as strong advocates for their patients, ensuring their voices are heard, needs are understood, and rights are respected. This includes navigating complex systems, collaborating with providers, and ensuring follow-through on care plans.
- Culturally competent care: Nurses need to be mindful of cultural considerations and communication styles when caring for older and developmentally delayed individuals. This includes using plain language, offering alternative communication methods, and respecting individual preferences.
- Interprofessional collaboration: Nurses can work collaboratively with other healthcare professionals, social workers, and case managers to develop comprehensive care plans, bridge communication gaps, and ensure continuity of care.
- Technology and resource utilization: Nurses can leverage technology like telehealth, mobile apps, and online resources to empower patients and facilitate access to care, especially in underserved areas.
Systems-Level Changes:
- Improved care coordination: Implementing models of collaborative care management, including patient navigators and care coordinators, can streamline access to services, address fragmented care, and ensure proper follow-up.
- Enhanced geriatric training: Increasing geriatric training for healthcare professionals will equip them with the knowledge and skills necessary to meet the specific needs of older adults, including those with cognitive or developmental delays.
- Accessible communication strategies: Healthcare systems should implement clear communication protocols, utilize language translation services, and offer alternative communication methods (e.g., visual aids, assistive technology) to ensure access for all patients.
- Addressing workforce shortages: Investing in healthcare workforce development, ensuring appropriate staffing levels, and providing adequate compensation are crucial to address staff shortages and improve quality of care, especially in long-term care settings.
- Anti-discrimination practices: Implementing and enforcing anti-discrimination policies within healthcare systems can help address implicit bias and ensure fair treatment for all patients, regardless of age or disability.
Proposed Policy for Assisted Living Facilities:
Policy: All residents of assisted living facilities with identified chronic health conditions or disabilities will be assigned a designated care coordinator or advocate. This individual will be responsible for:
- Conducting a comprehensive needs assessment: Understanding the resident's medical history, medications, functional limitations, communication needs, and preferences.
- Developing and coordinating a personalized care plan: Collaborating with healthcare providers, social workers, and family members to develop a comprehensive plan addressing all medical, social, and emotional needs.
- Facilitating access to healthcare services: Assisting residents with appointment scheduling, transportation arrangements, navigating insurance complexities, and communicating with healthcare providers.
- Advocating for residents' rights and needs: Ensuring residents' voices are heard, their autonomy is respected, and their care aligns with their wishes and preferences.
- Providing ongoing support and education: Educating residents about their health conditions, medications, and self-care strategies.
Rationale: This policy addresses the specific vulnerabilities of residents in assisted living facilities by providing them with a dedicated advocate and care coordinator. This centralized point of contact will ensure continuity of care, overcome communication barriers, navigate bureaucratic hurdles, and empower residents to participate actively in their own healthcare. It can also reduce reliance on overworked facility staff and improve overall quality of life for residents with complex needs.
Sample Answer
Ms. Sharrod's story exemplifies the complex and layered barriers that older and developmentally delayed individuals often face when trying to access healthcare. Her case highlights several key challenges:
1. Lack of Coordination and Advocacy: As Ms. Sharrod aged and her needs increased, the assisted-living facility's limited ability to manage chronic conditions and navigate healthcare bureaucracy left her vulnerable. Without a dedicated caregiver or advocate, simple tasks like scheduling appointments, navigating insurance complexities, and ensuring follow-through became insurmountable obstacles.