Risk Stratification & Intervention Follow Up Care for High Risk Patients Mary Beth Byrnes, MSN, RN

CARE MANAGEMENT PROCESS Identify Stratify Prioritize Highest risk patients through systematic risk stratification process Intervention Evidence Based Guidelines Establish Goals & Objectives Establish Interactive Care Plans (SM) Multi-disciplinary Care Team Focused on Medical, Behavioral, Socio- Economic Conditions/Barriers, Utilization Evaluation Ongoing & revised according to outcomes Systematic measurement, testing & analysis Outcome is effective, efficient, & improves quality

Identify High Risk Planned Care at Every Visit  Risk Assessment  Chart Alerts Registry Reports Notification from Hospital Admission & Discharge Notification Self-Reporting

Risk Stratification Age Co-existing Health Conditions Number of Medications Functional Deficits Non-adherence to treatment plan Self-Care & Knowledge Deficits Socio-Economic Issues Support System Utilization

Depression Risk Factors Age Co-Morbidities Number of Medications Significant Loss - Spouse, other significant family member, pet Family Care Giver (Spouse or other generational dependent) Social Isolation/Absence of Social Support Fatigue/Sleep Disturbance Chronic Pain Functional Disability Current Alcohol/Substance Abuse Disorder Psychosocial Causes  Cognitive Distortions  Chronic Stress  Poor Self-Health Rating

Risk Factors for Falls Age (>80 Years of Age) History of Falls Gait Dysfunction Balance Dysfunction Use of Assistive Devices Visual Deficit Medications (Hypotensive, CNS Suppressants) Arthritis/Chronic Pain Diarrhea/Urinary Frequency Impaired ADL’s Depression Cognitive Impairment

Cumulative Risk 0 – 1 Risk Factors – Seniors have a 27% chance of a fall each year >4 Risk Factors – Seniors chance of a fall increases to 78% each year Tinetti: 1998

Instrumental Activities of Daily Living - IADL

Interventions Evidence Based Guidelines Functional Deficits Knowledge Deficits Socio-economic Issues Barriers to Achieving Goals Support System

High Risk Follow Up Follow Up Date & Method Agreed Upon  Task List with Scheduled Reminder Identify Goals Met – Unmet Identify Barriers to Unmet Goals Revise Plan Set Next Follow Up

Case Study

85 Year Old Male Hypertension on 1 medication Active and Working until 02/2011  Fell on ice injuring ribs (1 st Fall)  Hospitalized for abdominal pain with subsequent cholecystectomy SNF  Severe Depression – Short Time in Mental Health System 02/2011 to 01/2012  Fell 3 more times – Out of State/County  Fracture Hip (01/2012)  Fell at Home 5 weeks after discharge (5 th Fall)  Readmitted surgical repair wound dehiscence Did not know family members until 01/2012

Low

Goals & Barriers Self-Management Goals  Increase Physical Activity  Increase Self-Care Activities Barriers  Difficulty Dealing with Functional Loss  Inability to Recognize Depression  Inability to Recognize Need for PT

Interventions Inpatient & Outpatient PT/OT Home Care  Evaluation of Home Environment – Fall Prevention Medication & Psychiatric Counseling Respite Care – 1 Week Ongoing Outreach – Patient & Wife Encourage Participating in ADL’s and Movement Transitional Care Nurse

Questions?