BOX 4-1
The Burns Family

Ray Burns is a 59-year-old maintenance supervisor who quit smoking 2 years ago. Forty pounds overweight, he was recently diagnosed with Type 2 diabetes and sleep apnea. Ray reluctantly uses a CPAP (continuous positive airway pressure) machine at night to control his apnea. He has recently acknowledged that his excess weight and lack of regular exercise are threatening his long-term health, and he is serious about renewing the more disciplined approach to diet and exercise that served him well in his youth. He has joined a weight loss group at work and is learning to make healthier choices, monitor his conditions, follow prescribed treatment, and maintain supplies of medications and batteries, test strips, and tubing for his medical devices. He has settled into a daily routine that includes measuring his blood glucose level at home and during the day at work, downloading each reading onto his computer, and generating a trend report to send by e-mail to his doctor. Ray welcomes the structure and encouragement provided by the weight loss program. By adhering to his current diet and exercise plan, he hopes to eliminate his diabetes medication alto ether

Ray’s parents live nearby and are quite frail. Ray’s father, Ed, requires constant supervision due to a stroke he sustained 3 years ago. Ed is a tall and stout man who needs assistance with bathing, dressing, walking, and transfers from bed to chair. Because of difficulty swallowing, he requires tube feedings. Ray’s mother, Dorothy, is small in stature and has emphysema and severe arthritis, so she can help her husband dress but she cannot help with more strenuous tasks, like bathing and transfer ring. Ed and Dorothy receive 6 hours daily of in-home services from the Program for All-inclusive Care of the Elderly (PACE).* Personal care aides help Ed bathe, and an occupational therapist monitors his functional status, oversees his exercise program, and evaluates his use of assistive devices. A nurse recently set up an electronic monitoring system for both Ed and Dorothy, enabling family members and PACE staff to track their medication taking remotely. She is also helping Dorothy use the nebulize and oxygen concentrator that were recently prescribed. Either Ray or his wife Patricia stops by every day to help with tube feedings and oversee Ed and Dorothy’s medication routine.

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*PACE is a capitated system for delivery of in-home, clinical, and adult day care services to nursing home–eligible older adults living in the community (Mukamel et al., 2007).
SOURCE: Clinical experience of committee member Judith Matthews.



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