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Intense Clinical Care Management Case Studies –Adult Diane Jackson, CM, Geisinger.

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Presentation on theme: "Intense Clinical Care Management Case Studies –Adult Diane Jackson, CM, Geisinger."— Presentation transcript:

1 Intense Clinical Care Management Case Studies –Adult Diane Jackson, CM, Geisinger

2 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

3 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

4 SNF cont. Next steps for this patient ?

5 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

6 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

7 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 ?

8 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

9 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

10 LOC cont. Discharge Plan?

11 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 ?

12 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

13 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

14 PCP office referral cont. What are the key assessment questions ? What is the POC for the pt. and his wife ?

15 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?

16 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

17 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

18 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

19 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”?

20 Heart Failure cont. “ What is the Plan of Care for this pt.”?

21 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

22 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. ?

23 Heart Failure Call Intervention Review case with PCP Reinforce new treatment plan Continue daily weights CM follow-up call next day

24 Questions? 24

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