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

• 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 1cont.

• 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 2cont.

• What is the Plan of Care for this patient?

Case Study 2 cont.

• 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

• 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 3cont

• You are the CM , calling 48hrs post discharge• What are the assessment questions you need

to ask?

Case Study 3 cont.

• 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 4cont.

• 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 4cont.

• What are the next steps for this patient?

Case Study 4cont.

• 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 5cont.

• Assessment questions?• Plan for this patient?

Case 5cont.

• 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• 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 6cont.

• Next steps for this pt.?

Case Study 6cont.

• 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• 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 7cont

• 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 7cont.

• Plan for this patient?• Where do we start?

Case Study 7cont.

• 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 sounds

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 8cont.

• 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• 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 9cont.

• 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 9cont,

• What's the Plan of Care for this patient?

Case Study 9cont.

• Diuretic titration• Daily wts,• Education• ECHO• Call to CARDS • LABS• Home Health as indicated• Medication adherence review• Diet review

Case Study 10cont.

• 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 10cont.

• What are the next steps for this pt.?

Case Study 10cont.

• 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