1. Adult Case Studies Transitional Care Diane Jackson, CM, Geisinger

2. Case Study : Transition of Care 75 year old new to CM CM calls pt 24hrs post discharge Lives alone S/P 5 day adm. for Pneumonia HS. HTN,CAD,Osteoporosis Meds prior to adm. Lopressor 5Omg bid, Lasix 40mg as needed,ASA 81mg qd,Zocor 40mg 1 qd

3. What are the assessment questions for this pt.? TOC cont.

4. Did you have your medications filled? If no, why? Were you able to afford medications? What medications were you on prior? If Home Health ordered,have they contacted the patient? When is the first visit 24hr?? Was all equipment received? ie Oxygen

5. TOC cont. Edema Do you have any swelling ? If yes is it resolved in the morning ? Was the pt. taking their Lasix during their hospital stay ? Lasix restarted on discharge ?

6. TOC Cont. Breathing How is your breathing ? Any different than what is normal for you ? How did you sleep last night ? Pillows? Any problems doing activities ? ie steps Any cough, if yes secretions?

7. TOC cont. D/C meds Lopressor, ASA, Zocor, Tylenol #3 for pain, SOB since d/c, Was not SOB in the past. Edema slight ankles, upon awaking present Secretions clear Not wt. self No Home Health/ Pt. thought he was to be on Oxygen?

8. TOC cont. What’s the plan for this pt ? CM f/u plan ?

9. TOC Plan Review case with PCP ie Lasix restart, same day appt. ?? Post discharge appointment 5 days Contact Home Health, same day visit ASAP Pulse Ox Contact in patient Case Manager Follow-up call that day and next morning