Panel: Preventing Readmissions in those with Memory Impairment October 16, 2014 Kim Butrum MS, RN, GNP: Moderator Jim McAleer MPA Leslie Zun MD Nicholas Jauregui MD

The Evidence Memory impairing diseases are a significant area of concern in reducing readmission rates. NRPC So Cal Readmissions Update October 16, 2014

Kim Butrum MS, RN, GNP Vice President- Health Service Silverado Utilizing Clinical Outcomes to Prevent Readmission in those with Dementia October 16, 2014 Kim Butrum MS, RN, GNP Vice President- Health Service Silverado

Use of Clinical Outcomes: The Silverado Experience Through the collection of clinical outcomes over the past 18 years, Silverado has reduced both their 30 day readmission rate and transfer to the acute rate to industry leading levels. : NRPC So Cal Readmissions Update October 16, 2014

How do we do it? Our culture Education and training Early identification and management of a behavioral or functional change Alignment with strong partners for both extra support and palliative care/hospice care at different points of the disease NRPC So Cal Readmissions Update October 16, 2014

Don’t Prevent Readmission – Promote Community Retention… October 16, 2014 Presented by Jim McAleer., MPA President/CEO Alzheimer’s Association

Objectives Know what community programs and services can make a difference The Caregiver matters Preventing readmission begins long before the patient leaves the hospital Alzheimer’s Association Case Study NRPC So Cal Readmissions Update October 16, 2014

Dealing with Patients who have Memory Impairment in the Emergency Department October 16, 2014 Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine RFUMS/Chicago Medical School Mount Sinai Hospital Chicago, Illinois

Objectives Understand the role of the emergency department in evaluating memory impaired patients To determine if the patient has a medical, psychiatric, substance use or behavioral problem

Case #1 64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history. What further information is needed? What to look for in the physical exam? What testing is indicated?

Medical Clearance Purpose Primary Purpose - To determine whether a medical illness is causing or exacerbating the psychiatric condition. Secondary Purpose - To identify medical or surgical conditions incidental to the psychiatric problem that may need treatment.

Primary Purpose Etiology Drug and alcohol intoxication or withdrawal Medical Hypoglycemia Hyperthyroidism Delirium Dementia Head Trauma Temporal Lobe Epilepsy Psychiatric

Delirium vs. dementia Delirium Dementia Onset Acute Slow Awareness Reduced Clear Alertness Fluctuates Normal Orientation Impaired Memory Perception Hallucinations Intact Thinking Disorganized Vague Language Word finding difficulty

Primary Purpose - Differentiate Medical from Psychiatric Etiology Age >45 years old Prior psychiatric/medical history Abnormal vital signs Physical examination findings Cognitive deficits Focal neurologic findings New or different psychiatric complaints Laboratories? Advanced testing?

What information is needed? Case #1 64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history. What information is needed? Prior psychiatric history - none History of medical problems – DM, HTN, CVAs Use of drugs and alcohol - Denies What to look for in the physical exam? Vital signs – tachycardia & hypertensive Focal deficits – right sided weakness Signs of intoxication – Heightened consciousness What testing is indicated? CBC, electrolytes, UDS, alcohol level EKG, CT scan head, CXR Diagnosis – Delirium from Hyperthyroidism

Take Home Points Memory Impaired may present to the Emergency Department for social, behavioral, medical, substance use or psychiatric reasons. It is important to identify which problem or problems is/are involved Does the patient need to be admitted/readmitted?

Contact Information Leslie Zun, MD Mount Sinai Hospital 1501 S California Chicago, IL  60608 773-257-6957 zunl@sinai.org

Nicholas Jauregui MD Supportive Care Medical Group Preventing Readmissions in those with Dementia Across the Post Acute Continuum October 16, 2014 Nicholas Jauregui MD Supportive Care Medical Group

Care Across the post- acute continuum Dr. Jauregui is board certified in Hospice and Palliative Care Medicine Medical Director: Supportive Care Medical Group, an active SNF and housecall medical group in Southern CA NRPC So Cal Readmissions Update October 16, 2014