CASE 1: Where to discharge Mrs. Smith?
Key Learning Points
Care Team
- Compare and value the roles of specific health professionals in facilitating a safe discharge
- Describe the interdisciplinary discharge process
Discharge Location
- Describe pros/cons of discharge to home vs skilled nursing facility
- To understand the importance of function (ADLS/ADLS), cognition, and social supports in helping to determine discharge
Transitions of Care
- To appreciate overall understanding of complexities of creating a safe transition of care for patients
Mrs. Smith is an 83 yr old woman with known CHF, HTN, CAD, GERD, Osteoarthritis was admitted from home with shortness of breath and lower extremity edema. She is also noted to have fallen the day of admission. She lives with her elderly husband who called 911 to bring her to the hospital. This is her 3rd admission to the hospital during the past 6 months. During the hospital course, she was noted to be confused at times. She did not have any fractures from the fall, but is bruised on her left side. She has been in the hospital now for 4 days and was diuresed 10 pounds. As per the medical team, she is now ready for discharge.
Where should she be discharged to? What more information would you want to know?
WILL HAVE PT/OT note
Additional info: Known to care team (goal is to get the interns to ask these ?s)
Case Manager/RN (or PT/OT if we have)
-Function- at home, she is able to walk around with a cane, she needs can get dressed and feeds herself, but has some help with grocery shopping and bill paying from her husband and daughter; since the fall, during this hospitalization -she has been more unsteady on her feet and requiring a walker. She is also now having more trouble with getting dressed and bathing.
-What were her other hospitalizations for this year?- CHF exacerbations each time
Social Worker
-Social supports- lives at home with elderly husband who has few medical problems. He still drives, but gets around more slowly these days. A daughter is nearby, but cannot come daily to help.
-Cognition- history of mild to moderate dementia
Pharmacy:
-Who takes care of her medications?- Husband gets medications from pharmacy and helps her take them.
-Does patient/family understand how/why to take medications? When asked what medications patient is on- neither patient nor husband could give full list.
Mrs Smith and her husband are insisting on her being discharged back to home. They say that they are doing fine and can take care of themselves. The medical team is concerned about Mrs. Smith going home so soon after a fall and her multiple recent hospital admissions.
What are the options for discharge location? Skilled Nursing Facility vs Home
Why are the advantages and disadvantages of each?
What could be done at each in order to decrease likelihood of readmission?
Case Manager/RN:
-Skilled Nursing/Rehab-- why eligible- multiple recent admissions for CHF- unsteady gait, unclear if taking medications well at home-would benefit from "skilled needs" (ie, blood pressure/weight management, rehabilitation); would anticipate short stay, would give time to make sure med regimen appropriate, gain strength, get additional support system in the home; Rehab generally about 1 hour/day
-Home- would greatly benefit from Visiting nurse- would benefit from "skilled needs" --blood pressure/weight management, medication management, PT/OT referral for rehabilitation. Visiting nurse would come 1-2 times a week depending on skilled need. He/she would also monitor weights, discuss diet, do detailed medication management, and home safety evaluation. PT/OT could come for 1 hour/day- 2-3 times a week (if have
Social Worker-
-Medicare eligibility for short term Home Health Aide for help with dressing/bathing. Discuss how often and what can do (ex/ help with ADls/IADLS, 2 hours ,5days a week)
Pharmacy
-Medication Reconciliation- on all discharge and transfer documents
-Pill box- would help with compliance and understanding of how taking meds at home; can be initiated by visiting nurse
MD Facilitator- this would be the time to also discuss need for communication via discharge summary and/or phone call to primary care provider about hospitalization and goals for discharge. Husband/daughter should also be informed.
Case 2: Discharge to home care with multiple needs
Key Learning Points:
(1)Care Team
- Role of CRC/VNA-> coordinating home care needs
- understanding the need for clear instructions/orders to better coordinate care
- pharmacy role in patients discharged on anticoagulation
- pharmacy role in explaining medication changes to patients and family members
- pharmacy role in suggesting drug level follow up and surveillance labs
(2)Discharge Document:
- Listing all medications added or discontinued and explaining why
- All wound care-> giving precise of where wound is
- All patients on tube feeds-> type, rate and when to give
(3)Follow Ups
- Always with PMD appointment
- Always with INR follow up (who labs will be sent to) and what doses were given in hospital
- Panel 5/CBC on patients on IV abx
You are caring for a 85 year old with dementia, hypertension and atrial fibrillation leading to an embolic R CVA with residual left sided weakness. She is initially admitted for fever.
It is now day 4 of her hospital stay and you are discussing her care at discharge rounds.
After a positive UA, her Urine Culture has grown E Coli that is sensitive only to IV Cefepime or Meropenem.
She also was noted to have difficulty handling POs and on speech and swallow evaluation was thought to be a severe aspiration risk. At the urging of her family a PEG tube is placed and she is initiated on tube feeds.
She also noted to have a sacral decubitus ulcer.
Her Coumadin dose is adjusted and most of her anti-hypertensives are held because of low blood pressures throughout her stay.
She lives at home with a supportive family who want her to return home.
You are preparing her for discharge home and presenting her at care coordination rounds. What services will you request and to whom will you direct your requests?
They should request pharmacy help for:
Coumadin dosing and when to check INR
Drug level follow up for new Abx- in this case not needed but yes in many others
Surveillance labs (CBC, panel 5)- in this case not needed but yes in many others
Counsel family on meds that were discontinued and why-> med rec with the team and family at discharge
They should direct requests to CRC:
Need referral to home infusion for PICC line care and home IV Abx
Need home care nursing referral for further teaching on how to administer feeds
Need home care nursing referral for wound care
Need home care nursing or home infusion for INR draws
Need CRC to arrange for all equipment and feeds to be delivered to home prior to discharge
Take time to explain how CRC role differs from social worker-> mention training
Take time to explain role and training of home care RN.
Please examine the discharge document below. What critical information needs to be added? What information is unneeded?
Document will include and does not need:
All details of urinalysis and full description of barium swallow evaluation copied word by word from medview.
Will be missing:
Order for PICC line care
Description of wound and what needs to be done to care for it
Order for INR will lack name of PMD to send results to
PEG tube feeds will not include type, rate and timing of feeds
No follow up appointment listed
No description of which meds were held and why
No antibiotic stop date
Case 3:Uninsured Patient/”New Diabetic”
Key Learning Points:
(1)Care Team-
- Understanding social work role in care for uninsured
(2)Follow Ups
- Affordable medication choices
- Clinic resources
The morning after admission you are presenting at care coordination rounds a 53 year old admitted with HHNK and Hypertension Urgency.
He had had a diagnosis of diabetes and hypertension but lost his job and insurance.
He has been started on lantus, Humalog for his diabetes and losartan/HCTZ for his hypertension.
Who on the care team will you request help from?
Social Work- Will help to start Medicaid application process – (this process usually secures payment for the inpatient stay only. Additional documents and a personal visit to the MA office post discharge are required to get insurance.)
Pharmacy-
-Will review new medications and how to administer insulin; also
- can help in finding less expensive medication regimens see below.
- canhelp the provider on med choices
-can educate the patient in the room about their med changes
CRC
- Can arrange for a home care visit. Helpful for someone to review BSG checks and insulin administration at home and assure that he has received all medications and supplies needed. (Penn Home Care will do charity in Philadelphia, but not for NJ)
What special concerns do you need to be attentive to in this patient?
Medications!!- Introduce 4 dollar formularies and contrast with the cost of the medications listed above
Supplies- Will need glucometer and strips(!!), syringes, and EtOH pads
Follow up- explain clinic resources for uninsured patients.