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Coming Together to Improve Communication

My story is about care coordination for a patient with chronic pain and several other health conditions. She had recently been in the ICU for 2 weeks for an infection and repeat trips to the emergency room. By observing the patient’s behavior while she was in the clinic to see her primary care doctor, conversations via telephone, and talking with her pharmacy, I discovered she was still receiving narcotic medication even though her pain management physician and primary care doctor were not prescribing them any longer. The medication side effects were causing cognitive impairment and prevented her from properly caring for herself, picking up on symptoms of infection/illness, and managing regular follow up appointments. We had a team meeting to include the pain management physician, primary care doctor, patient and her husband, and a plan was made to begin weaning her off the narcotics over time. She is doing much better. She has followed up with her doctor and specialist and has had no additional trips to the ER or hospitalizations. We were able to reach a new level of honesty, communication, and understanding of safety amongst herself, her family and her medical team.

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