1. Small Group Care Management Exercise: Adult Intense Care Management Case Studies

2. Objectives Utilize case studies in small group exercises to support discussion of clinical care management including patients post ER visit, patients post hospital discharge, and patients needing intense clinical care management.

3. Instructions Each group will be given a case Assign a scribe and also a spokes person Review the Case Present a Plan of Care There are not any right or wrong answers.

4. Case Study 1 55 year old male, calls the office stating he is not feeling well, same day appointment given PMH negative Pulse irregular rate 102 BP 118/82 C/O feeling lightheaded EKG reveals Atrial Fib. Controlled

5. Case Study 1 cont. What are the next steps for this pt? Can they be managed as an outpt? What is the Plan of Care ?

6. Case Study 1 cont. PCP agrees to outpt management based on patient presentation CM follow-up call in the morning Education PCP follow-up appointment

7. Case Study 2 35 year old women presents to office c/o right calf pain. No other complaints Negative PMH Medications: BCP for 10 years Patient is sent for a stat doppler which is positive for a DVT Can this patient be managed as an outpatient?

8. Case Study 2 cont. What is the Plan of Care for this patient?

9. Case Study 2 cont. Check pharmacy benefit for Lovinox coverage Contact ER for first dose of Lovinox Home health if indicated Follow-up call by CM PCP appointment

10. Case Study 3 60 year old patient referred post discharge New to CM S/P hospitalization LOS 3 Days COPD exacerbation 40 years 1 ppd smoking history,at present has a patch on Discharged on Advair,Nebulizer with Duo-Neb.qid Prednisone taper,Antibiotic Lives with wife

11. Case Study 3 cont You are the CM, calling 48hrs post discharge What are the assessment questions you need to ask?

12. Case Study 3 cont. Does the patient understand his medications? Inhaler teaching Nebulizer ie cleaning Follow-up appointments Secretions Dyspnea

13. Case Study 4 70 year old female adm. post fall in her home, over a throw rug Prior to hosp. was amb with a straight cane and stated that she has had a few falls in the past but, did not need to seek health care Dx. Left wrist fx, Insurance Medicare Advantage Lives alone

14. Case Study 4 Support daughter who works full time and lives 45min away Hs. HTN, Osteoporosis, CAD, Planned RTH replacement 5yrs. ago PT/OT eval recommends SNF adm. for therapy at present time amb. 50 feet with walker Reconditioned./ Right handed Family conference pt refuses SNF agrees to Home Health, daughter states that she will do the best that she can to help her Mother. Medical Home was not made aware Pt is d/c to home

15. Case Study 4 cont. CM calls patient 24hrs after discharge Pt states that she is home since yesterday morning and has not be able to get around, cannot get out of bed at this point. Daughter left last night for son’s graduation. Pt states that she has not heard from Home Health. Cannot get to bathroom or has nothing to drink.

16. Case Study 4 cont. What are the next steps for this patient?

17. Case Study 4 cont. CM request stat visit from Home Health. CM contacts D/C hosp. to review d/c plan, was not made aware that there were any concerns with the discharge. CM contacts insurance CM to discuss SNF for PT/OT

18. Case Study 5 CM receives referral from high risk list 12 year old boy has been in the ER 5 times in 3 months with complains of SOB History of Asthma DX age 5 Last PCP appt. 1 year ago check up Office not aware of ER visits Medications: Rescue Inhaler no maintance meds No PFT’s noted

19. Case 5 cont. Assessment questions? Plan for this patient?

20. Case 5 cont. Does the child have a Peak Flow Meter? Previous exacerbations? Home assessment? Has he been seen by Peds Pulmonary? Action plan? Triggers? PCP appointment

21. Case Study 6 45 year old single mother Presented to ER not feeling well BS 500 After work up DX DM Type 11 BP 190/100 new DX HTN LOS 3 days Discharged to home Has not see a PCP in 10 years BMI 40 CM calls pt 48hrs post discharge

22. Case Study 6 Medications: Metformin 500mg bid.ASA 81MG,Zocor 40mg qd, Accupril,Atenol Not checking BS, has a One Touch Ultra Has RX Plan states co-pay to high cannot afford medications Needs to get back to work ASAP or will loose her job. Works in a factory stands all day. 7am-330pm States she is only worries about her children ages 10/12

23. Case Study 6 cont. Next steps for this pt.?

24. Case Study 6 cont. Education PCP appointment Medication assistance program’s/Walmart Program CM meet with pt in office Continued support and reinforcement Focus on POC that meets needs of pt.

25. Case Study 7 New referral from PCP New patient at office 50 year old man with history of MI at age 40 DM Type 11 last HA1C 12 EF 10%/ICD Wt.345lbs Sedentary life style Medications: Coreg,Lipitor,ASA,Lasix 40mg as needed,Prinivil,Atenol, Lantus,Novolog coverage

26. Case Study 7 cont Lives with disabled wife and 3 children 10/11/15 Would like to return to work Current income MA/wife works as a phone operator Insurance HMO with co-pays Trouble affording medications and office visits Not candidate for transplant

27. Case Study 7 cont. Plan for this patient? Where do we start?

28. Case Study 7 cont. Daily wts. Blood Sugar Monitoring Cardiology PCP f/u Endocrine Life Style management Education

29. Case Study 8 10 year old boy with history of Shaken Baby Syndrome at 11 days old by father Lives with Foster Family Seizure disorder on Diastat as needed for Grand Mal lasting longer than 3 min/ on seizure meds Cortical Blindness Tubing feedings, unable to move, makes sounds

30. Case Study 8 Has been in the ER 3 times in the last 2 weeks for seizures Has not had seizure in a year Prior medication was effective Foster Mother comes in for appointment, states that she gives the med as directed and it does not work

31. Case Study 8 cont. Have Foster Mother explain when she gives the medication and how Review when the seizures occur, have her keep a log when ? Describe seizure Does he have a temp. Arrange for appointment with Pediatric Neuro Contact Pharmacy check on medication adherence Any issues with feeding tube ie vomiting, residual Blood work

32. Case Study 9 35 year old female Cardiomyopathy Viral/ has ICD EF 15% In process of being evaluate for a transplant PCP refers patient to CM for follow-up Presented to the office c/o difficulty sleeping and inability to do activities Does not wt at home, gained 5LBS since last PCP appt. 1 month ago

33. Case Study 9 cont. Pulse Ox 95% at rest, during ambulation 90% Medications: Coreg,Lisinopril,Lopressor,ASA,Aldactone PCP advises adm. pt refuses states I have children at home. Ages 8/5 Lives with husband who is supportive

34. Case Study 9 cont, What's the Plan of Care for this patient?

35. Case Study 9 cont. Diuretic titration Daily wts, Education ECHO Call to CARDS LABS Home Health as indicated Medication adherence review Diet review

36. Case Study 10 cont. 70 year old adm. to hospital for a planned TKR Hs. HTN,elevated Lipids and a TIA Medications: Lopressor,Zocor,ASA, Pt was on 20mh Lasix pre hospitalization CM calls pt. 24hrs after discharge Pt. states that she has been restless since home and not able to sleep States that she has some swelling in her ankles Case reviewed with PCP states will address at appt.

37. Case Study 10 cont. What are the next steps for this pt.?

38. Case Study 10 cont. Reinforce with PCP pt was on Lasix prior and has not been receiving the medication. Ask to restart prior to f/u appt. PCP will not start Lasix attempt to have patient seen the next day Have patient start daily wts. F/U with patient next day