Case Management in Robert Frost Country

This is a story I wrote 5 years ago. It was published in a magazine called, The Case Manager. A friend, editor and hero, Catherine Mullahy helped me immensely and lightly edited for the better I believe.We are still providing choice in Vermont for nursing home care and I hope we do it as well as one can. I got permission to publish this once in my blog, my anthology of writing I hope a legacy to explain who I am, what I did and what I believe. This is my own version. The published version is available at the link below.




Case Management in Robert Frost Country

Official copyrighted version published in The Case Manager Nov/Dec 2006
Link:
http://www.sciencedirect.com/science/journal/10619259


By Mary E. Gerdt 2006


As I began to write what I thought would be a poetic article, I paused to explore

Robert Frost, the man. He is famous in this area for his poetry and his lifestyle of writing

and taking walks in nature. He gave me a goal to work toward.

I envisioned him sitting in his Ripton cabin in need of long term care and out of

money (he was a poet after all). My phone rings. It is a call from a case manager or his

doctor or home health nurse or even from Robert himself. Then I make a few phone calls

and am unable to leave a message. He is out for one of his famous nature hikes. He can't

go as far as he used to and now rides an all terrain scooter of sorts. Finally I get the man

on the phone. He is not sure what I am talking about. Choices for Care? It is a Vermont

Medicaid program for long term care. I lost him. The famous scholar needs me to slow

down and explain. It is a Medicare project. A waiver to the state to provide long term

care in your choice of setting. He is stuck on the word waiver. Nothing rhymes with that

one. I change the subject. So you write poetry? "A little" he replies with a little giggle.

"Silly nurse" he is thinking. Finally we come to agree on a date and time to meet. I will

be doing a clinical assessment. OK he says. He has learned by now I will say things he

has never heard and if he agrees, I will visit and give him more words he does not

understand. Like most people though, he is polite and a little lonely. A visitor would be

nice on a snowy afternoon on the mountain.

Looking into his history, I review what I have of his medical records, home health

OASIS assessment, nursing notes, doctor notes, application. There is very little here.

Diagnoses, medications, generic repetitive statements/care plans.

Nothing about "the man"

I go on the internet. Here is one guy I can search for on the web.

He wasn't born in New England after all. California? His dad took him there and

then died of Tuberculosis. I envisioned young Robbie losing his Dad, hero, his male role

model. And to boot his mother had to support the family. They returned to New England.

I read through all the losses in his life. His children. A three year old, a newborn, one died in

childbirth, a suicide. He lost his precious wife. Only later in life, he holed up here in this

cabin where he could live with nature, write poetry and cry silent and alone when the

cold winds howled.

I had always thought of him as a Vermont native. I myself am not and have been

pestered at times by the multigenerationals. "Flatlander" I have been called. My husband

is a fourth generation Vermonter. He says when we married I assumed his status as a

"real Vermonter". I do not push this to other natives. They would not understand.

So when I read where Robert has been, England, Massachusetts, New Hampshire, I

cannot classify him as a native. But when we assess eligibility residency is simple. You

live here and you have been in the U.S. 5 years, you are a Vermonter.

So I have new feelings about this man when I know where he has been, his losses,

his successes.

Financial eligibility is a quick review. Famous poet. Any assets? Income? No

surprise if I see small numbers. Many arrive at late life with pennies on the dollar. His

taxes must be a bear up here. Flatlanders driving the property values up. What will we do

when we are 80 something? He will still have to do the long forms and submit bank

statements, accounting details for Long Term Care Medicaid eligibility.

I prepare the papers and fill in the forms where I can. I look up my map where the

cabin is. Reminds me of The Legend of Sleepy Hollow. The maple leaves have fallen and

now the road is a swirl of red and yellow and brown. I go up, up, up the hill. What a

place. Views far to the west, The Adirondacks in the distance. The road narrows and

winds. Little bridges creak as I cross them. Funny how this road goes. First this way than

that. Following a deer path perhaps. I keep stopping to check the map.

I think about the program, Choices for Care, a new job for me and 11 other nurses

in Vermont. One for each region. Two for Burlington, the biggest city. We are paving

new ground. We are all enthusiastic about helping Vermonters make the choice between

long term care settings.

The previous Home based Medicaid Waiver was granted by "slots". The funding

depended on legislative action (Robert might call that an oxymoron). Now the Agency of

Human Services of Vermont has gained the status to offer choices to all eligible

Vermonters.

In other words, when a client meets clinical and financial eligibility for Choices

for Care (nursing home eligible/long term Medicaid eligible), they may choose to receive that care in a

traditional nursing home, home based or residential care settings. These clients are often referred to

as "Skilled" or "Intermediate" level of care. They often choose home based when they can.

Robert wants to stay at home.

I arrive at the cabin. My curious side looks at the little details. Indicators of

personality traits. Knick knacks, photos, plaques, awards, pets, glimpses of the life before

old age.

Smells, foods, views out windows. Wishing I could tap into the memories. When

their children were born and died and married and had children. When all the world

bought his poetry and we recited the poem in English class. "Walking through the Woods

on a Snowy Evening…." I want to ask him about his work, his life, his poetry. I found

many of the verses impossible to understand. Others so easy. But would he stoop to

talking to me, a nurse, about poetry. Besides, I only have two hours to get this

assessment done and then get back to the office.

He opens the door. He is shorter than I thought. Famous people usually are.

He is a little shy or maybe wondering why this persistent nurse wants to visit him on a

snowy afternoon.

I notice the lack of female presence. This is a male cabin. His wife has been gone

a long time. "Like yesterday" is how he remembers her. I get a little teary. We both laugh.

I run through the usual routine of questions. Are you able to perform the various

Activities of Daily Living? Any medical issues? Memory/cognition problems? Short term

problems, long term problems, behavior issues, informal supports.

I measure his level of care with the tools we were given and by my own

experiences in acute care, post acute care, long term care, insurance, home care. I think

how my own crooked path has brought me to the man who wrote about the path less

traveled. And how my career in case management has brought a thread through it all.

How when I was laid off in 1996 (nurses were never laid off), my personal devastation

brought me to the most rewarding and exciting less traveled road of case management.

I review the worksheet. He meets criteria for the program.

I fill out certification papers to get him started. We talk about case management

agency choice. Then personal care service choice. Then we discuss personal emergency

services. Companion time. Adult day services. We discuss how if it does not work out for him at home he

could go to a nursing home bed or residential care home if bed available.

We discuss the financial application and how that will be the next step to finish.

His case manager can help him with this.

By the end of our two hours he looked appropriately dazed. The forms, the

signatures, the criteria, protocols. He says he is glad he is the poet and I am the nurse. I

tell him I like to think of myself as both nurse and a writer and poet. Except that my

verses are not so perfect in meter and rhyme. My prose not desired by big publishers and

scholars. I took one college course in literature. I am a slow reader. But I enjoy

expression of ideas, sharing of stories. Hearing a tale from a client is to me the ultimate

sharing of two people in our small world. A poem without framework. A living

impromptu moment of energy remembered only in our minds and so transient.


Robert's on the mountain.

Robert's on the mountain.

He's not coming down

not coming down

not coming down

Robert's on the mountain

Today

He's goin for a walk

Down the less traveled path

Not coming down
Not coming down

Robert's on the mountain

To stay

Robert's goin for a walk

Looking at a bird

Writing his words

Living up there today

Today

Robert's on the mountain

Now going to stay

Writing his poems

Welcoming the new day

Live in the present.

Stay where you are.

Robert's on the mountain

His choice is there.



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Reprint orders: E-mail authorsupport@elsevier.com or phone (toll-free) 888-834-7287; reprint no. YMCM 439



1 Mary E. Gerdt, RN, CCM, is the Choices for Care long-term care clinical coordinator in the Department of Disabilities, Aging and Independent Living for the State of Vermont, Middlebury region.



PII: S1061-9259(06)00374-2


doi:10.1016/j.casemgr.2006.08.010



© 2006 Mosby, Inc. All rights reserved.