Chapter 3: Direct Care Outpatient Clinic Visit Chronologies and Network Hospital Admission
Cisifus Primary Care Clinic
At the initial Cisifus primary care clinic visit, the PCM questioned the patient in an attempt to determine the extent, and appropriateness, of her care over the past year. She was unable to remember much specific information. Upon examination she was noted to be hypertensive, in early congestive heart failure, with laboratory results revealing worsening renal function. The PCM adjusted the dose of her medications, and gave her a return appointment for one month.
At this follow-up visit, the PCM noted a small ulcer on the bottom of her left foot and a mild temperature differential between her feet. The PCM prescribed local wound care for the foot, provided materials for dressing changes and entered a referral for a routine appointment in the Olympus orthopedic and podiatry clinics. She was scheduled for a return Cisifus clinic appointment in two weeks.
Olympus Orthopedic Clinic
Two weeks later, the orthopedic surgeon confirmed a diagnosis of osteoarthritis of the right knee and noted that there was no evidence of any problems with the left prosthetic knee joint. He prescribed a NSAID medication for pain and discharged the patient for follow-up on an “as needed” basis. There was no mention of the foot ulcer.
Olympus Podiatry Clinic
The patient called the podiatry clinic at Olympus to try to make her referral appointment, but was told that no routine appointments were available within the next six weeks. However they did advise her could come without an appointment and the podiatrist might be able to see her as a “walk-in.”
She presented herself to the Olympus podiatry clinic the following day (Thursday) and the podiatrist immediately scheduled her for local debridement of the foot ulcer, to be performed the following day.
During his medication reconciliation the podiatrist received conflicting information from the patient vs. the last available PCM AHLTA note with regard to her current medications and there was inadequate information to accurately define her stated antibiotic allergies. Over the next 24hours, the Olympus podiatrist attempted to contact the referring PCM at Cisifus. E-mail requests were unanswered and attempted telephone communications were unsuccessful, possibly because the three healthcare facilities did not share a common phone directory.
The podiatrist postponed the surgery and instructed the patient to obtain the necessary clinical information from her PCM and then make a return appointment ASAP or if the ulcer on her foot worsened. He gave her directions for local treatment and a number to call immediately if her condition changed. The podiatrist documented the fact that surgery had been cancelled for that day, the basis for the cancellation, and his directions to the patient, in a detailed note in AHLTA. As it was Friday and Cisifus was not open on the weekend, the patient stated that she would go to the Cisifus clinic the following Monday to get the information or make contact if conditions changed.
Cisifus Primary Care Clinic
The patient returned to the Cisifus primary care clinic on Monday to get the medication information. She told the clinic clerk of the cancellation of her podiatry surgery and that the ulcer on her foot “looked worse”. She was evaluated by the Triage corpsman and was noted to have enlargement of the foot ulcer and discoloration of two toes of that foot. Additionally, her femoral artery pulses were weak, and no other pulses were palpable in her left leg. The temperature differential between her feet was more pronounced.
Her PCM, who was unaware of the outcome of the Podiatry visit, called the surgery clinic at Valhalla, but the clinic staff reported that they had no appointments available for seven weeks, and that she should go directly to the Emergency Department (ED). She then went to the Valhalla ED. The ED was unaware of the urgency of her situation, as apparently no contact with them had been made by either the PCM or surgery. Facing an estimated 6-hour wait to be seen, and following a failed call to her PCM, she elected, instead, to seek care at the network ED with which she was familiar and that was associated with her original network providers. The network ED, realizing that she needed inpatient admission, contacted Valhalla to refer her to be admitted, but the Valhalla admissions office reported that “no beds were available” and refused to accept her in transfer.
Network Hospital
She was admitted to the network hospital and treated with antibiotics and local wound care. No vascular testing was performed, but the temperature differential between her feet was noted.
During this stay, the attending physician at the network hospital contacted the managed care support contractor to inquire about coverage of a combination of laser revascularization, injection of stem cells and topical hyperbaric oxygen to enhance circulation in the beneficiary’s lower extremity. Having read about several different clinical trials involving each of these interventions as an approach to peripheral vascular disease, he wanted to propose an off-protocol treatment regimen involving all three approaches. However, the beneficiary was ready for discharge before he heard back about the coverage determination. After an in-patient stay of three days, the patient was discharged on antibiotics with instructions to follow-up with her military PCM as soon as possible. There was no evidence that at the time of discharge that the network provider attempted to contact the Cisifus Clinic regarding the need for expedient follow-up.
QUESTIONS
1) What is the responsibility of the referring provider with regard to follow-up of requested consults?
2) What mechanisms are available to support this follow-up continuity of care responsibility?
3) What is responsibility of the institution/provider to assure that patients have the information necessary to engage in their self-care? (Domain: Patient Centered Care)
a. What assessment of patient understanding should be performed to define the limitations of patient self-care?
4) In this case what factors contributed to the lack of accurate and timely provider/facility communications?
5) What are the implications medical/legal for the EMR documentations issues noted in the case to this point?
6) What are some potential contributing causes each of the access issues? (clinics, ED, hospital in-patient)
7) What determines whether a treatment regimen or intervention is a TRICARE benefit?
8) What criteria determine whether a form of healthcare is a nationally accepted medical practice that has been proven to be safe and effective?
a. Are there exceptions for some types of “unproven care”? (Only care that is proven safe and effective can be reimbursed under the TRICARE benefit.)