Care Transitions Workshop – Third Year Medical Students

Emory Department of Medicine

Discharge Summary Case Exercise

During this section of the workshop, we will discuss a case in the context of a discharge summary. After this session, you should be able to:

  1. Discuss the role of the outpatient clinician in facilitating safe transitions of care.
  2. Structure the post discharge visit
  3. Perform post discharge outpatient best practices including:
  4. Review of a discharge summary
  5. Medication reconciliation
  6. Develop a post discharge care plan in the out-patient setting
  7. Identify and address factors that present a risk for re-hospitalization during the post

discharge visit

  1. Discuss the role of inter-professional team collaboration and care coordination in the management of a discharged patient.
  2. Identify availablecommunity resources for the discharged patient.

Scenario:

You are Mr. Scott’s primary care physician. He presents to you today for a follow-up visit post discharge. He has been hospitalized 5times over the last 6 months. Wt today is 235lbs, BP 130/80, HR 90.
With your knowledge of his medical, social and functional history as indicated on the PPT slides, please perform the following tasks:

A. Goals for the Post Discharge Visit

1. List the goals of a post discharge visit?Which of these goals would you like to accomplish during Mr. Scott’s post discharge visit with you today?

a. Ensure that the symptoms for which he was hospitalized have resolved.

b. Ensure that the disease is optimally controlled and adjust medications if necessary.

c. Ensure that he is on all the right medications for his disease processes.

d. Determine if there are any laboratory tests or investigations that need to be done either as recommended by the discharging team or as a follow up to the disease process or medications he is taking. Ensure that these tests are completed.

e. Determine if there are any outstanding consults and ensure that these are completed.

f. Determine care needs that present a risk for re-hospitalization and address these needs.

2. List activities that you would perform during this visit to help you accomplish these goals.

a. Complete a history and physical on the patient.

b. Review the discharge summary and discharge recommendations.

c. Reconcile the patient’s medications.

d. Determine social and functional needs and refer to appropriate members of the health care team.

B. Discharge Summary Review

Listthe elements of a discharge summary care that should be evaluated by the PCP during the post discharge visit?

a. Reason for hospitalization

b. Hospital course of disease

c. Patient’s status at the time of discharge

i. Resolution of disease

ii. Functional status

iii. Cognitive Status

iv. Discharge Labs

d.Changes made to medications and discharge medicines

e. Pending laboratory tests and investigations

f. Pending consults

C. Appropriate medication reconciliation and management

Reconcile his admission and discharge medications. Are there medications that you would like to start, discontinue or change the dose?Indicate a reason for the change you would like to make.

a.Restart metoprolol to optimize afterload reduction and heart failure management.

b.Discontinue Lantus Insulin and switch back to Glipizide – Ability of this 78 yr old patient who is cognitively impaired and lives alone to cope with self administration of insulin.

c.Change the dose of furosemide to 40mg BID – He is volume overloaded as indicated by the weight change over a 2 week period.

D. Support Services

1. In the light of Mr. Scott’s frequent re-hospitalization, identify his care needs that may be contributory to his readmissions

a.Medical Needs

i. Multiple medical diseases with frequent exacerbations

ii. History of dementia with possibilityof

a.Poor medication compliance

b.Poor dietary compliance

c.Poor understanding of disease and medications

b.Functional Needs

i.Increasing difficulty with performing IADLs such as cooking

ii.May be eating the wrong things - canned foods, fast foods

c.Social Needs

i.Lives alone, only checked on 3ce a week by niece

ii.With the history of dementia, most likely unable to manage his medications, diet or apply other self management skills

2. List any ancillary services that you think he would benefit from?

a.Home Health agencies

i.Nurse - Patient education and medication monitoring

ii.Home Health Aide for IADLs

iii.PT/OT for de-conditioning and cardiac rehabilitation

b.Community Services

i.Senior Centers or Adult Day Care Centersfor daily interaction, education classes, exercise, appropriate meals and medication supervision

ii.Meals on Wheels

iii.Change in residence – Assisted Living/PCH, Nursing Home

E. Post Discharge Care Plan

What are the elements of a care plan that you would develop for Mr. Scott during his visit with you today?

  1. Medical
  2. Medication changes as indicated above to optimize the disease control.
  3. Laboratory tests –
  4. Chemistry panel on account of patient being on an increased dose of furosemide with no potassium supplements, and an adjusted dose of lisinopril at discharge
  5. Complete blood account to ensure that there has been no further drop in his blood count.
  6. UA, M/C/S – To ensure resolution of UTI
  7. Referral to Consultant
  8. Will refer to GI for an EGD as recommended in the discharge summary.
  9. Education
  10. Will refer patient and caregiver to Pharmacist and HH Nurse for education on CHF self management skills.
  11. Will refer patient and caregiver to hospital or community based CHF education classes.
  12. Functional
  13. Will refer to a Home Health Agency for provision of a Home Health Aide in view of increasing difficulty with IADLS
  14. Arrange for meals on wheels in view of difficulty cooking and risk of eating high salt content meals as a quick measure
  15. Will refer to a Home Health Agency for provision of a PT/OT for rehabilitation in view of increasing difficulty with IADLS
  16. Will refer patient to hospital or community based cardiac rehabilitation exercises
  1. Social
  2. Arrange a meeting with family members to discuss issues with his care including his recurrent episodes of CHF most likely due to dementia, inability to manage his medications, diet or apply other needed self management skills; potential safety issues as a result of living alone.
  3. Consideration by family of a change in residence such as a Personal Care Home or Assisted Living facility for closer supervision.
  4. Refer to resources in the community such as an Adult Day Care for closer daytime supervision.

Revised 11/18/111