Mrs. Santiago is an 87-year-old woman who has presented at the Emergency Department (ED) of the hospital where you worked five times in the past three months. On each occasion, she complained of severe spasms of pain in her left hip and knee that on two of the five occasions caused her to fall at home and come to the ED via ambulance. Fortunately, on these two occasions, she suffered only minor bruises and scrapes. You have been asked to see Mrs. Santiago in the ED for two reasons: 1) to ensure a safe discharge since her diagnosis of OA does not permit admission to the hospital and 2) to ensure that a longer term plan is in place to prevent another visit to the ED for her OA pain.

From her previous ED medical charts, you have the following information:

1)      Medical History: Mrs. Santiago was hit by a cab driver while she was walking home from her job as a waitress when she was 57 years old. She had a steel rod placed in her left femur and a full cast on her right leg. She was in traction for 2 months. After spending several months in the hospital and a physical rehabilitation center, Mrs. Santiago was sent home. However, she stated that, “it always hurt to walk, and every time the weather changed she just wanted to stay in bed.” She had to quit her job as a waitress and only went out to grocery shop at the corner store and to the local health clinic when she could get there. She can no longer use the subway and relies on her church to find people to take her to the doctor. In the past 10 years, she has been diagnosed with hypertension and diabetes, which she regulates with medication “when she has the money to buy it.” About 3 years ago, Mrs. Santiago complained to a neighborhood health clinic resident that her pain in her hip and knee had gotten much worse. X-rays confirmed a diagnosis of osteoarthritis (OA) in her left knee and hip. The physician prescribed NSAIDS and participation in a disease management program. Mrs. Santiago never followed through with either treatment. She reported, in past ED visits, that she just takes aspirin and uses a hot water bottle when she “gets to hurtin’ something awful.” During two of her previous visits, she was given steroid injections to relieve her pain, and she says this is the only thing that works. Currently, she has no regular physician, and she has never seen an orthopedic surgeon or rheumatologist for her OA. The ED physician gave her another injection and has recommended that she see a surgeon for possible hip replacement surgery. Mrs. Santiago reports that “she ain’t havin’ no surgery in this hospital.”

2)      Occupational History: Mrs. Santiago was a waitress until she became permanently disabled after the cab accident. She receives a small Social Security Disability check monthly. She also has Medicare. She has never applied for any social services including Medicaid or SSI or HEAP. She lives in a rent-controlled apartment and says she gets by “with help from her church and the local food pantry at the end of each month.”

3)      Family History: Mrs. Santiago came to New York City from Puerto Rico when she was 22 years old with her husband. They settled in her current apartment in the Bronx. She worked as a waitress and he was a day laborer. They had one child. Her husband died in a construction site accident when she was 53 years old. A year later her only son, Roberto, was killed in a gang related shooting. He was mistaken as a gang member on his way home from work at a local diner as a dishwasher. Mrs. Santiago has lived alone since the death of her husband and son. She was active in her church until her accident. Since that time, she has lost touch with many of her friends. She has one sister in Puerto Rico that she talks to on the phone once a month. A friendly visitor comes from her local church once a week to give her communion.

4)      Psychological History: Mrs. Santiago denies that she has been depressed. However, previous records indicate that she has lost 30 pounds since her first ED visit and that she has a flat affect. She also reported in her last two visits that she wants to sleep all the time and doesn’t even want to visit with her church members anymore when they come to see her. She says she is tired of being in pain all the time.

Using Table 2 (the biopsychosocial health needs and formal services required to address them) answer the following questions regarding this case:

• Of the seven assessment areas outlined in the power point, what information do you have for each?
• Given the current situation, which of the seven areas will be most prominent for your assessment and development of a treatment plan for the short term and the long term?
• Formulate questions you would ask in each of these areas.

How important is it to gain a better understanding of Mrs. Santiago’s culture and religious beliefs to complete her assessment and care coordination plan? What would you want to know and how would you go about getting this information?

As an ED social worker how would you design and develop a social work care coordination model that you could use with Mrs. Santiago and similar patients to help minimize their use of the ED inappropriately and appropriately maximize their use of community-based services to manage their illnesses? What would be your short-range discharge plan to get Mrs. Santiago out of the ED and home safely? What plan would you put in motion to minimize her inappropriate use of the ED in the future?

Of the four ways that were identified in the Table (and PowerPoint file for this section) to address the needs of older OA patients, which ones would be prominent in this case? Justify your choices.