Download Part 10 PPT

Small Group Care Management Exercise:
Adult Intense Care Management
Case Studies
Objectives
• Utilize case studies in small group exercises to
support discussion of clinical care management
including patients post ER visit, patients post
hospital discharge, and patients needing
intense clinical care management.
Instructions
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Each group will be given a case
Assign a scribe and also a spokes person
Review the Case
Present a Plan of Care
There are not any right or wrong answers.
Case Study 1
• 55 year old male, calls the office stating he is
not feeling well, same day appointment given
• PMH negative
• Pulse irregular rate 102
• BP 118/82
• C/O feeling lightheaded
• EKG reveals Atrial Fib. Controlled
Case Study 1 cont.
What are the next steps for this pt?
Can they be managed as an outpt?
What is the Plan of Care ?
Case Study 1
cont.
• PCP agrees to outpt management based on
patient presentation
• CM follow-up call in the morning
• Education
• PCP follow-up appointment
Case Study 2
• 35 year old women presents to office c/o right
calf pain. No other complaints
• Negative PMH
• Medications: BCP for 10 years
• Patient is sent for a stat doppler which is
positive for a DVT
• Can this patient be managed as an
outpatient?
Case Study 2
cont.
• What is the Plan of Care for this patient?
Case Study 2
cont.
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Check pharmacy benefit for Lovinox coverage
Contact ER for first dose of Lovinox
Home health if indicated
Follow-up call by CM
PCP appointment
Case Study 3
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60 year old patient referred post discharge
New to CM
S/P hospitalization LOS 3 Days COPD exacerbation
40 years 1 ppd smoking history,at present has a patch on
Discharged on Advair,Nebulizer with Duo-Neb.qid
Prednisone taper,Antibiotic
Lives with wife
Case Study 3
cont
• You are the CM , calling 48hrs post discharge
• What are the assessment questions you need
to ask?
Case Study 3
cont.
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Does the patient understand his medications?
Inhaler teaching
Nebulizer ie cleaning
Follow-up appointments
Secretions
Dyspnea
Case Study 4
• 70 year old female adm. post fall in her home,
over a throw rug
• Prior to hosp. was amb with a straight cane
and stated that she has had a few falls in the
past but, did not need to seek health care
• Dx. Left wrist fx,
• Insurance Medicare Advantage
• Lives alone
Case Study 4
• Support daughter who works full time and lives 45min away
• Hs. HTN, Osteoporosis, CAD, Planned RTH replacement 5yrs.
ago
• PT/OT eval recommends SNF adm. for therapy at present time
amb. 50 feet with walker
• Reconditioned./ Right handed
• Family conference pt refuses SNF agrees to Home Health,
daughter states that she will do the best that she can to help
her Mother. Medical Home was not made aware
• Pt is d/c to home
Case Study 4
cont.
• CM calls patient 24hrs after discharge
• Pt states that she is home since yesterday
morning and has not be able to get around,
cannot get out of bed at this point.
• Daughter left last night for son’s graduation.
Pt states that she has not heard from Home
Health. Cannot get to bathroom or has
nothing to drink.
Case Study 4
cont.
• What are the next steps for this patient?
Case Study 4
cont.
• CM request stat visit from Home Health.
• CM contacts D/C hosp. to review d/c plan, was
not made aware that there were any concerns
with the discharge.
• CM contacts insurance CM to discuss SNF for
PT/OT
Case Study 5
• CM receives referral from high risk list
• 12 year old boy has been in the ER 5 times in 3
months with complains of SOB
• History of Asthma DX age 5
• Last PCP appt. 1 year ago check up
• Office not aware of ER visits
• Medications: Rescue Inhaler no maintance
meds
• No PFT’s noted
Case 5
cont.
• Assessment questions?
• Plan for this patient?
Case 5
cont.
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Does the child have a Peak Flow Meter?
Previous exacerbations?
Home assessment?
Has he been seen by Peds Pulmonary?
Action plan?
Triggers?
PCP appointment
Case Study 6
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45 year old single mother
Presented to ER not feeling well
BS 500
After work up DX DM Type 11
BP 190/100 new DX HTN
LOS 3 days
Discharged to home
Has not see a PCP in 10 years
BMI 40
CM calls pt 48hrs post discharge
Case Study 6
• Medications: Metformin 500mg bid.ASA 81MG,Zocor 40mg
qd, Accupril,Atenol
• Not checking BS, has a One Touch Ultra
• Has RX Plan states co-pay to high cannot afford
medications
• Needs to get back to work ASAP or will loose
her job. Works in a factory stands all day. 7am-330pm
• States she is only worries about her children ages 10/12
Case Study 6
cont.
• Next steps for this pt.?
Case Study 6
cont.
• Education
• PCP appointment
• Medication assistance program’s/Walmart
Program
• CM meet with pt in office
• Continued support and reinforcement
• Focus on POC that meets needs of pt.
Case Study 7
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New referral from PCP
New patient at office
50 year old man with history of MI at age 40
DM Type 11 last HA1C 12
EF 10%/ICD
Wt.345lbs
Sedentary life style
Medications: Coreg,Lipitor,ASA,Lasix 40mg as
needed,Prinivil,Atenol, Lantus,Novolog coverage
Case Study 7
cont
• Lives with disabled wife and 3 children
10/11/15
• Would like to return to work
• Current income MA/wife works as a phone
operator
• Insurance HMO with co-pays
• Trouble affording medications and office visits
• Not candidate for transplant
Case Study 7
cont.
• Plan for this patient?
• Where do we start?
Case Study 7
cont.
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Daily wts.
Blood Sugar Monitoring
Cardiology
PCP f/u
Endocrine
Life Style management
Education
Case Study 8
• 10 year old boy with history of Shaken Baby
Syndrome at 11 days old by father
• Lives with Foster Family
• Seizure disorder on Diastat as needed for
Grand
Mal lasting longer than 3 min/ on seizure
meds
• Cortical Blindness
• Tubing feedings, unable to move, makes
Case Study 8
• Has been in the ER 3 times in the last 2 weeks
for seizures
Has not had seizure in a year
Prior medication was effective
• Foster Mother comes in for appointment,
states that she gives the med as directed and
it does not work
Case Study 8
cont.
• Have Foster Mother explain when she gives the medication
and how
• Review when the seizures occur, have her keep a
log when ? Describe seizure
Does he have a temp.
Arrange for appointment with Pediatric Neuro
Contact Pharmacy check on medication adherence
Any issues with feeding tube ie vomiting, residual
Blood work
Case Study 9
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35 year old female
Cardiomyopathy Viral/ has ICD
EF 15%
In process of being evaluate for a transplant
PCP refers patient to CM for follow-up
Presented to the office c/o difficulty sleeping and inability to
do activities
• Does not wt at home, gained 5LBS since last
PCP appt. 1 month ago
Case Study 9
cont.
• Pulse Ox 95% at rest, during ambulation 90%
• Medications:
Coreg,Lisinopril,Lopressor,ASA,Aldactone
• PCP advises adm. pt refuses states I have
children at home. Ages 8/5
• Lives with husband who is supportive
Case Study 9
cont,
• What's the Plan of Care for this patient?
Case Study 9
cont.
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Diuretic titration
Daily wts,
Education
ECHO
Call to CARDS
LABS
Home Health as indicated
Medication adherence review
Diet review
Case Study 10
cont.
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70 year old adm. to hospital for a planned TKR
Hs. HTN,elevated Lipids and a TIA
Medications: Lopressor,Zocor,ASA,
Pt was on 20mh Lasix pre hospitalization
CM calls pt. 24hrs after discharge
Pt. states that she has been restless since home and not able
to sleep
• States that she has some swelling in her ankles
• Case reviewed with PCP states will address at appt.
Case Study 10
cont.
• What are the next steps for this pt.?
Case Study 10
cont.
• Reinforce with PCP pt was on Lasix prior and
has not been receiving the medication. Ask to
restart prior to f/u appt.
• PCP will not start Lasix attempt to have
patient seen the next day
• Have patient start daily wts.
• F/U with patient next day