Transcript Case Management-Discharge Planning Considerations

What you need to know about
Care Delivery at Temple!
2013 TUHS House Staff Orientation
Case Study
Patient X is a 72 year old
History of Present Illness:
• chest pain, shortness of breath, palpitations, pedal edema
Past Medical History:
• hypertension, diabetes, atrial fibrillation, renal failure, heart failure, and
frequent falls
Exam:
• blood pressure 180/98, heart rate 112, respiratory rate 26, pulse
oximetry 95% 2L, afebrile
• lungs- rales 2/3 bilat; irreg/irreg heart rhythm and rate; 2+ pedal edema; R
Foot with erythema, warmth, tenderness; unsteady gait
Ancillary testing:
• Chest x-ray- CHF; BNP 2115; Creatinine 5.6
Admitted to Floor. Put on IV lasix, 02, imdur, beta blocker, and hydralazine.
Also started on IV vanco
Care Delivery Issues
Heart Failure:
Core Measure Compliance
Heart Failure Disease Navigation Program
Documentation- “acute or chronic”,
“systolic or diastolic”
Renal Failure:
Acute on Chronic
Nephrology consultation
Will need Dialysis- complicates care and
discharge planning
Cellulitis in a Diabetic:
Manage glucose during an infection
Patient ends up with osteomyelitis- will
require 6 weeks of intravenous
antibiotics-this will complicate discharge
planning- to home or to a skilled nursing
facility
Gait Instability:
History of falls. Fell while in hospital.
Importance of “out of bed” and physical
therapy to prevent deconditioning and
falls and to improve function and safety.
Will need fall assessments, physical
therapy- in hospital and post discharge
Complex patient. Will need coordinated team effort to ensure safe
and effective patient-centered care
Care Delivery Team
Review Assessments and Roles of:
1. Physician
2. Nursing
3. Case Management
4. Social Work
5. Physical Therapy
And how they all coordinate as a TEAM in providing
Safe, Effective, Efficient, Timely, and PatientCentered Care
Physician Assessment/Role
• Clinical Assessment, treatment plan, and
documentation
• Plan for the Day, Stay, and Way
• Work Rounds
• Multi-disciplinary Rounds
• Coordination of Care with Team
• Medication Reconciliation
• Patient and Family education
• Transitions of Care
Accountable Care Unit Model
Each Unit is geographic and has a:
• Unit Based Medical Director who has oversight for the
clinical, service, and cost outcomes of the Unit
• Partnered management with nurse manager/UBMD leaders
and structured multidisciplinary rounding
Accountable for:
• Efficiency of care
• Patient throughput
• Decreasing variation
• Use of clinical care guidelines
• Management of utilization
• And teaching
Interdisciplinary Plan of
Care - IPOC
• Focus : IPOC is patient focused and
disciplines add to the IPOC as they
become involved in the patient’s care
• Where : The IPOC is located in the Care
Plan tab of the Medical Record
Falls Prevention
• Any patient designated Low Risk or High Risk are
placed in the Fall Prevention Program- Morse Scale
used to assess fall risk
• The yellow armband (At Fall Risk) is placed on the
same arm as the patient ID band
• The Fall Risk Magnet is placed by the patient name on
the locator board outside the patient’s room and on
the door frame.
• Use of low rise bed and or bed alarms
• Assure assistance and supervision are provided with
elimination, transfers and ambulation
• Provide patient/family education
• Recommend referral to PM&R for safe ambulation and
transfer techniques
What happens if a patient
does fall?
• A Midas Incident/Event report must be done. It needs
specific information about the fall: Where, when, how,
injuries?
• Post Fall Assessment to be completed by the team
• Falls are tracked and trended because of the Midas
report
• The data is used to help us improve care
Close Observation
Level 11:1 Supervision-Suicide Precautions
Patient an immediate threat to self
Staff must be within arm’s length of
patient-including when in bathroom
Level 2Field of Vision/Visual Observation
Patient danger to self or others
At risk for elopement
Staff must be in same room/area
Visual contact with patient at all
times
2:1 observation permitted
Level 3Enhanced Safety Observation
Patient has delirium/dementia without
violent behavior
May have impulsive behavior requiring
more frequent observation
Staff must observe whereabouts,
behavior, and patient condition every 30
minutes
Level 4Fall Precautions
Morse scale to identify fall risk
Staff must observe whereabouts,
behavior, and patient condition every 60
minutes
Collaborative effort to reduce falls
Notify RN if you assess any changes in
patient’s mobility
Telemetry & Pulse Oximetry
• Two classifications for telemetry
– Class I (e.g. a-fib, a-flutter, certain medications)
• If the patient needs to be transported, he/she must be on a
cardiac monitor and accompanied by nurse or doctor (or both)
– Class II (e.g. other diagnoses requiring monitoring)
• The patient can be transported off telemetry and without a nurse
or doctor
• All patients requiring telemetry will have a patent IV access
• Pulse Oximetry:
– Verify the physician order for both telemetry and continuous pulse
oximetry (pulse ox)
– The order must include acceptable range for saturations
Discontinuing Telemetry
• Patients eligible for removal of telemetry monitoring
will be reviewed at shift report
– Criteria for removal has been established under the
direction of the Cardiology Medical Director
• If patient meets criteria after 48 hours on telemetry,
then an order must be obtained to discontinue
telemetry
• House staff/resident will be notified
– Attending physician has the option of reordering
telemetry
Department of Nursing
CLINICAL RESOURCE
MANAGEMENT DEPARTMENT
Primary functions• Coordinate a safe and timely discharge plan
• Secure reimbursement for care
• Collaboration with the team
• Daily Accountable Care Unit rounds
• Review of medical record
What is needed from you?
• H & P MUST be in the medical record for all
members of the team to begin their work
• Document patient’s contact numbers in
H & P if you interview care giver
• Clear documented plan of care
• Forms and prescriptions completed timely
• Communicate, Communicate, Communicate
How we can assist you?
• Case Managers and Social Workers can
assist you with developing the plan for a safe
transition to after care
• Consult with team to determine appropriate
level of care for transition
• Provide resources to you
• Available as a resource to you and team
When to consult Social
Worker
• Patient incapable of
decision-making
• No next of Kin
Information
• Social Work to assess
provision of resources in
the community to local
health district and public
welfare office
• Patient admitted with a
psychiatric involuntary
(302) or voluntary (201)
need for continued
psychiatric treatment
when medically stable
• Patient has active drug
or alcohol issues
• Assistance in placement
of Homeless patients
When and Why Should Physical
Therapy be Ordered?
• Is the patient at his functional mobility baseline?
• Will medical treatment alone restore the patient to his
baseline level?
• Have there been attempts to mobilize the patient prior
to therapy referral
• Is patient able to participate in therapy?
• Do you plan to transfer to a SNF or Rehab within the
next 48 hours for PT services?
More about PT
PT is contraindicated if:
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Spine not cleared from trauma/METS
X-rays/MRI pending
No clear Weight Bearing status
Patient with BEDREST activity orders
HgB <7
INR > 5
PT is not necessary if:
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Safely discharging home
Want home PT for endurance or safety check
Want outpatient PT for chronic issues
Patient is baseline functionally
Want a walking pulse ox
Other PM&R Services
Occupational Therapy:
Upper extremity dysfunction
Hand/arm/shoulder splinting
Splint, boots, shoes
Activities of Daily Livi
dysfunction
Acute Rehab assessment
Speech Pathology Services:
Diagnostic and therapeutic
services forDysphagia
Speech-Language dysfunction
Cognitive Impairments
Voice Disorders
Mobility Aides:
Trained aides to enhance
patient mobility. Prevent
patient debility that can cause
secondary complications
Physical Medicine and
Rehabilitation:
Consider early consult for
musculoskeletal related issues
or need for inpatient rehab.
Case Management-Discharge
Planning ConsiderationsHome Care
• Visiting Nurse
• PT
• IV Therapy
• OT
• Speech
• Home care aide
• Home Hospice
Skilled Facility
Acute Rehabiltation
• Needs qualifying
• PT needs
diagnosis
• Wound Care
• Insurance
• Wound Vac
authorization
• IV antibiotic therapy
• PM&R team will
• Inpatient Hospice
provide physical,
• Needs insurance authorization occupational, and
speech therapies
Coming Back to our
Patient
• Physical Therapy evaluation indicates patient
would benefit from inpatient PT, not safe for
home discharge
• Medical team indicates patient will be
discharged on intravenous antibiotics
• Chronic Dialysis needed, new onset, Social
Work needs to arrange for a unit to accept
patient
Discharge Coordination
• Skilled facility placement must be coordinated with the
dialysis Social Worker
• Patient agrees to Hemodialysis site and Skilled
Nursing Facility
• Insurance Authorization must be obtained
• Patient medically cleared for transfer-documented
• Final arrangements made, time of transport
communicated
• Transfer orders complete before time of discharge
Alternative Discharge
Plan
• Patient has made progress in physical therapy
• Therapist recommends continued PT at Home
• Team modifies medication regime to insure
adherence
• Case Manager informed of plan and suggests
Visiting Nurse, PT and Home Health Aide
• Home infusion arrangements
• Agency selected; must coordinate with
Hemodialysis
• Informs team, discharge instructions completed
Temple Access Center
Need an appointment for a patient
being discharged?
• Place an order in MIS (Computerized Physician
Order Entry system)- it goes to our Access Center
• 2 hour turn around time for referral in-system/24
hours for external referrals
• Access Center will make the appointment and
enter it directly into MIS in the discharge
instructions
Summary
• Patients are complex
• Care Delivery requires a
multidisciplinary approach and great
teamwork
• Take advantage of your Temple Teameveryone is here to help you provide
safe, efficient, effective, timely,
equitable and patient centered care
• Welcome to your TUHS experience!