Transcript Part 8F PPT
Intense Clinical Care Management Case Studies –Adult Diane Jackson, CM, Geisinger Case Study : SNF Criteria • • • • PCP refers a pt to CM 84 yrs old Medicare Advantage pt Lives with daughter PMH: HTN,Osteo, S/P ORIF Left Hip 6 months ago • Meds: Lanoxin/Lopressor/Fosomax/ASA SNF cont. • CM meets with pt and daughter at office appt. • Daughter states that her Mother has been having difficulty getting around. • Mom has not been right since surgery • Several falls over the last 2 months • Difficulty with ADL’s SNF cont. Next steps for this patient ? SNF cont. • PT/OT evaluation • Home safety evaluation • Based on evaluation Home Therapy vs short SNF stay. • Evaluate need for Community Services • CM follow-up Case Study : Levels of Care • • • • • • • • 45yr. Old S/P LCVA adm. 2/20/11 ready for D/C 3/20/11 Right side flaccid Expressive Aphasia Has made little gains in PT/OT PMH: HTN has not seen PCP in years Stopped taking BP medications Works full time in IT at a local company Single has close male friend LOC cont. • Lives in a 2 story home • Outpt CM reviews case with inpt CM plan is rehab. States” she is to young for SNF “ • What further information does the CM need to work with inpt CM on providing the best care for this pt with in his benefit structure ? What is the d/c plan ? LOC cont. • CM contacts patients insurance company to verify coverage • 45 Rehab Days • 60 SNF day • Skilled home care only, aids are not covered • CM collaborates with insurance company CM on coverage issues LOC cont. • • • • Patient is discharge to Acute Rehab. LOS 40 days no progress made Discharged to SNF LOS Patient has 10 SNF days left and would like to go home. • Patient requires total care • Pivots bed to chair • 24/7 care LOC cont. Discharge Plan? Discharge Plan • • • • • • • • SNF CM contact’s PCP office to review discharge Friend plans on living with patient does not work Home Health Patient has 5 Rehab. days left for in home care Safety issues, Skin breakdown Caregiver stress/burnout DME ie Hosptal Bed.pressure relief device Will PCP make home visits? Transportation ? Case Study : PCP referral • • • • 86 Y/O HOH , WW11 Vet referred at PCP visit CM meets with pt. and wife Son lives 5 miles away offers little support Anemia, Gout, A FIB, HF, HTN, COPD, Pulm HTN • New start on Oxygen 2/L per min • Lives with spouse who has dementia and requires total care PCP referral cont. • Pt has had 3 hosp. for COPD in the last 6 months • 8 ER visits in the last year • Pt having difficulty with ADL’s/IADL’s PCP office referral cont. • What are the key assessment questions ? • What is the POC for the pt. and his wife ? PCP Referral • • • • • • Assessment of ADL’s/IADL’s patient and wife Home structure ie steps POA/Living Will Community Services Medication review ie Inhalers, Nebulizer Why does patient go to the ER and not call PCP? PCP referal • Patient states he needs to care for his wife and cannot leave her. His breathing gets so bad he needs to call an ambulance. • No Community Services • Wife has left stove on in the past • History of wondering Interventions • Discussed referral to Area Aging Office for evaluation of Adult Day Care services • Meals on Wheels • Medication education • Contact VA for services • Contact Respiratory Therapy at DME for equipment evaluation and education. • Home safety evaluation • CM follow-up Case Study : Heart Failure • PCP referral • 75 yr.old presents to the office with dyspnea,ankle edema and inability to sleep • Hs. CAD,HTN,S/P CABG 10 years • Pulse Ox 96 % at rest • Pulse Ox 92% ambulation 40 feet • Lopressor,Lanoxin, ASA, Zocor Heart Failure cont. • PCP requesting pt sent to ED • Pt. stating he does not want to go needs to care for his pets. “Can we manage this pt. as an outpt”? Heart Failure cont. “ What is the Plan of Care for this pt.”? Heart Failure cont. Outpatient Management • • • • • • • Home Health referral Daily weights does HH have Blue Tooth Scale Medication additions ie Diurtic,Potassium Home lab work Frequent follow-up by CM CM Home Health collaboration Follow-up appointment with PCP 2-3 days Case Study: HF f/u call • • • • • • • • • CM makes a f/u call to a HF pt. 65year old active man Last wt. 166 lbs/ Baseline 165lbs C/O SOB unchanged from baseline last contact Pt states that he has been SOB the last few day’s C/O being tired Wt. today 169lbs Lasix 40mg qd,Lopressor 100mg qd,ASA,Lisinopril 10 mg qd,Zocor 20mg qd What’s the next step ? • What is the Plan for this pt. ? Heart Failure Call Intervention • • • • Review case with PCP Reinforce new treatment plan Continue daily weights CM follow-up call next day Questions? 24