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Settings of Care Board Game
Vignettes
Case #1
• 90 y/o, lives alone in home; fell, couldn’t get up
• No family in area; has close neighbor who
checks on her daily and found patient on floor
• Sent to ED; no fractures, rhabdomyolysis,
infection
• Dehydrated, soft tissue musculoskeletal
injuries, pain, and unsteady gait
• Admitted to you because unsafe to go home
• In hospital; working with PT; pain & gait better
• What is the ideal discharge setting for her?
Case #2
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84 y/o widower
Cognitive deficits (MMSE 22/30)
Lives in senior independent living building
One daughter lives nearby and checks him
regularly (but not daily)
Patient diabetic, treated with OHGA
Admitted: Hyperglycemia and worse CRI
Insulin added with accuchecks (at least daily)
Daughter can give insulin and assist with
accuchecks, but can not do this every day
Patient has some financial resources
What is the ideal discharge setting for him?
Case #3
• 69 y/o female
• Lives alone in low income housing; no family
• Hospitalized with recurrent MRSA in 2nd Total Knee
Replacement
• Knee joint removed; needs antibiotics
• Allergic to vancomycin
• ID suggests daptomycin daily IV X 6 weeks
• Currently ambulating by pushing herself around in
a wheelchair
• What is the ideal discharge setting for her?
Case #4
• 78 y/o male living at home with family
• Severe Parkinson’s disease and some dementia
• Admitted for 3rd episode of aspiration pneumonia
in 3 months
• Responding to therapy, but hospitalization is
traumatic for him
• Family feels that, after this episode, patient should
not be re-hospitalized if he gets pneumonia again
• Family says they couldn’t handle having patient at
home if he aspirated and got short of breath.
• Patient’s health insurance is Medicare / Medicaid
• What is the ideal discharge setting for him?
Case #5
• 87 y/o female with baseline cognitive deficits
(MMSE 22/30)
• Lives in house with multiple extended family
• Falls and sustains pelvic fracture
• In hospital, is able to work with PT
• Improvement in endurance and gait is slow
• Family and patient have a long standing
agreement that patient will never go to a
“nursing home”
• What is the ideal discharge setting for her?
Case #6
• 85 y/o female living alone in apartment
• No family in area
• Slowly progressive cognitive decline; now
with paranoia
• Eats and drinks little because she fears
people are trying to poison her
• Admitted with dehydration
• Now hydrated and stabilized on psych meds
• She has no significant financial resources
• What is the ideal discharge setting for her?
Case #7
• 75 y/o lived in own home caring for frail
spouse
• Long hospitalization due to complications
after CABG, including respiratory failure
• Off ventilator, has PEG tube
• Beginning to eat
• Slowly works with PT (sits on edge of bed)
• Has a large sacral pressure ulcer requiring
wound vac therapy
• What is the ideal discharge setting for her?
Case #8
• 80 y/o female lives alone in own home
• Admitted with first episode of CHF
• Cognitively intact and only other medical
problem is poor vision
• One daughter who lives in the area, but
frequently out of town on business
• What is the ideal discharge setting for her?
Case #9
• 82 y/o widower
• Lives in senior independent housing
• Admitted; 3rd episode of CHF, felt secondary
to poor medication compliance
• Patient admits he often forgets to take some
of his medications or he gets them
confused; MMSE 21/30
• Has 2 children, but both live more than 30
miles away
• Patient has some financial resources
• What is the ideal discharge setting for him?