1. Complex Case Management

2. Complex Management  Heart Failure  Chronic Obstructive Pulmonary Disease  Frail Elderly

3. Heart Failure Heart failure (CHF) is a condition in which the heart's function as a pump is inadequate to deliver oxygen rich blood to the body.

4. Impact of Heart Failure  5.8 million people in US Dx of HF  670,000 new cases will be Dx 2010  34 billion spent per year  1 million hospitalizations  Leading case of hospitalizations 65>  33% pts. are readmitted in 3 months emedicine

5. Causes of Heart Failure  CAD  HTN  Diabetes  Valvular Heart Disease  Cardiomyopathy  Drug & Alcohol Abuse

6. Treatment of Heart Failure  Diuretics= Lasix,Bumex & Zaroxolyn  Ace Inhibitor= Lisinpril,Altace&Zestril  ARB’S= Micardis,Diovan & Cozaar  Life Style Changes  Fluid Restriction

7. Case Study  75 year old women  Hs. CAD and HTN  Medications: Toprol XL 100MG QD,ASA 81MG QD,Zocor 80mg HS,Lasix 20mg qd  S/P Hospitalization for Pneumonia  7 day LOS  Discharged to home alone

8. Post Discharge Call  CM/CC calls pts. 48hrs after discharge  Medication review  Do you have any swelling ? If yes is it gone when you wake in the morning ?  How did you sleep last night ?  How is your breathing?  Are you able to the things you did prior to being in the hospital ?  Do you have a cough ? Is yes is it productive?

9. Office Heart Failure Referral  PCP referral for HF  70 year old with newly diagnostic HF  History of MI,CAD,HTN &DM  Presented to office 1 week ago with lower leg swelling, SOB, inability to lay down  PCP treated with Lasix 40mg qd and ordered an ECHO which reveled an EF of 20%.

10. HF Management What education or instructions should be given to the pt. ???????????

12. DTP Smart Set Tool 10/25/201512 Diuretic Titration Protocol

13. COPD Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. Commonly known as emphysema and bronchitis. Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. Commonly known as emphysema and bronchitis.

14. Impact of COPD  24 million people  50% are not aware they have COPD  4 TH leading cause of death in the US  One of the leading causes of disability in the US National Heart Lung and Blood Institute.com

15. Causes of COPD  Smoking  Environmental Factors  Genetic Factors (AAT deficiency)  Frequent respitory infections in childhood

16. Treatment of COPD  Inhalers = Atrovent,Albuteral&Combivent  Nebulizers= DuoNeb  Steroids=Oral&Inhaled  Oxygen  Remove environment factors  Stop smoking

17. Case Study  58 year old male  Presents to PCP office C/O SOB with activity, productive cough for yellow secretions. C/O difficulty with secretions  History of smoking 2 ppd for 38 years  Frequent respiratory infections over the past year

18. Case Study COPD  Pulse OX is 90 during ambulation requiring periods of rest  Treatment: Z-Pack and tapering dose of Prednisone  Nebulizer qid with Duo Neb  CC/CM meets with pt. what should the education be focused on ?  What’s the follow-up plan for this pt ?

20. Frail Elderly Older persons (usually over the age of 75 years) who are afflicted with physical or mental disabilities that may interfere with the ability to independently perform activities of daily living. Older persons (usually over the age of 75 years) who are afflicted with physical or mental disabilities that may interfere with the ability to independently perform activities of daily living.

21. Impact of Hip Fracture  350,000 Fx per year  25% will return to their pre injury level of function  25% mortality rate in the 1rst year

22. Case Study  Mrs. Jones daughter calls stating that her Mom has been falling at home, not eating and at times forgetful. Mrs. Jones lives alone in a 2 story home and drives.  Appt. is made with PCP  PCP evaluates pts and orders testing  CC/CM meets with the pt. and her daughter at PCP appt.  What’s next ??