Intense Clinical Care Management Case Studies –Adult

Diane Jackson, CM, Geisinger

Case Study :SNF Criteria

• PCP refers a pt to CM• 84 yrs old Medicare Advantage pt• Lives with daughter• PMH: HTN,Osteo, S/P ORIF Left Hip 6 months

ago• Meds: Lanoxin/Lopressor/Fosomax/ASA

SNF cont.

• CM meets with pt and daughter at office appt.• Daughter states that her Mother has been

having difficulty getting around. • Mom has not been right since surgery• Several falls over the last 2 months• Difficulty with ADL’s

SNF cont.

Next steps for this patient ?

SNF cont.

• PT/OT evaluation• Home safety evaluation• Based on evaluation Home Therapy vs short

SNF stay.• Evaluate need for Community Services• CM follow-up

Case Study :Levels of Care

• 45yr. Old S/P LCVA adm. 2/20/11 ready for D/C 3/20/11• Right side flaccid• Expressive Aphasia• Has made little gains in PT/OT• PMH: HTN has not seen PCP in years• Stopped taking BP medications• Works full time in IT at a local company• Single has close male friend

LOC cont.

• Lives in a 2 story home• Outpt CM reviews case with inpt CM plan is

rehab. States” she is to young for SNF “

• What further information does the CM need to work with inpt CM on providing the best care for this pt with in his benefit structure ? What is the d/c plan ?

LOC cont.

• CM contacts patients insurance company to verify coverage

• 45 Rehab Days• 60 SNF day• Skilled home care only, aids are not covered• CM collaborates with insurance company CM

on coverage issues

LOC cont.• Patient is discharge to Acute Rehab. • LOS 40 days no progress made• Discharged to SNF LOS • Patient has 10 SNF days left and would like to

go home. • Patient requires total care• Pivots bed to chair• 24/7 care

LOC cont.

Discharge Plan?

Discharge Plan

• SNF CM contact’s PCP office to review discharge• Friend plans on living with patient does not work• Home Health• Patient has 5 Rehab. days left for in home care• Safety issues, Skin breakdown• Caregiver stress/burnout• DME ie Hosptal Bed.pressure relief device• Will PCP make home visits? Transportation ?

Case Study :PCP referral

• 86 Y/O HOH , WW11 Vet referred at PCP visit• CM meets with pt. and wife• Son lives 5 miles away offers little support• Anemia, Gout, A FIB, HF, HTN, COPD, Pulm

HTN• New start on Oxygen 2/L per min• Lives with spouse who has dementia and

requires total care

PCP referral cont.

• Pt has had 3 hosp. for COPD in the last 6 months

• 8 ER visits in the last year• Pt having difficulty with ADL’s/IADL’s

PCP office referral cont.

• What are the key assessment questions ?• What is the POC for the pt. and his wife ?

PCP Referral

• Assessment of ADL’s/IADL’s patient and wife• Home structure ie steps• POA/Living Will• Community Services• Medication review ie Inhalers, Nebulizer• Why does patient go to the ER and not call

PCP?

PCP referal

• Patient states he needs to care for his wife and cannot leave her. His breathing gets so bad he needs to call an ambulance.

• No Community Services• Wife has left stove on in the past• History of wondering

Interventions

• Discussed referral to Area Aging Office for evaluation of Adult Day Care services

• Meals on Wheels• Medication education• Contact VA for services• Contact Respiratory Therapy at DME for equipment

evaluation and education.• Home safety evaluation• CM follow-up

Case Study :Heart Failure

• PCP referral • 75 yr.old presents to the office with

dyspnea,ankle edema and inability to sleep• Hs. CAD,HTN,S/P CABG 10 years• Pulse Ox 96 % at rest• Pulse Ox 92% ambulation 40 feet• Lopressor,Lanoxin, ASA, Zocor

Heart Failure cont.

• PCP requesting pt sent to ED• Pt. stating he does not want to go needs to

care for his pets.

“Can we manage this pt. as an outpt”?

Heart Failure cont.

“ What is the Plan of Care for this pt.”?

Heart Failure cont.Outpatient Management

• Home Health referral • Daily weights does HH have Blue Tooth Scale• Medication additions ie Diurtic,Potassium• Home lab work• Frequent follow-up by CM• CM Home Health collaboration• Follow-up appointment with PCP 2-3 days

Case Study:HF f/u call

• CM makes a f/u call to a HF pt.• 65year old active man• Last wt. 166 lbs/ Baseline 165lbs• C/O SOB unchanged from baseline last contact• Pt states that he has been SOB the last few day’s• C/O being tired• Wt. today 169lbs• Lasix 40mg qd,Lopressor 100mg qd,ASA,Lisinopril 10 mg qd,Zocor 20mg qd• What’s the next step ?

• What is the Plan for this pt. ?

Heart Failure CallIntervention

• Review case with PCP • Reinforce new treatment plan• Continue daily weights• CM follow-up call next day

Questions?

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