Panel Participants: Elizabeth Buss, RN, BSN Lisa Stablein, RN, BSN Jackie Touch, MSN, RN-BC, CPN, CCM
At the end of this presentation, the participant will be able to: Identify barriers to efficient case management age e of the complex client Identify strategies to facilitate effective case management
Tony is an ex-term infant who had a complex neonatal course secondary to congenital heart disease. He is being followed in the high h risk infant follow up (HRIF) program. Recommended follow up after NICU discharge: pediatrician, cardiologist, several other specialists Funding source: CCS and managed care Medi-Cal Client of Regional Center Recommendations from first visit: therapies to address developmental delays and follow up with specialists Formal report sent to PCP, Regional Center, and family
Tony returned for his second high risk appointment: Receiving regular follow up with cardiology Receiving therapy twice a month (mother was unable to specify what type of therapy Not receiving i any follow up with other specialists as recommended Physical exam revealed abnormalities of feet and ankles: Orthopedic consult recommended Recommended follow up with specialists from first visit it (genetics and urology Formal report sent to PCP, Regional Center and family
Tony returned for a third high risk infant follow up visit approximately 8-9 months after his second visit. Regular follow up with cardiologist Physical therapy once a week No visits yet with urology, genetics, or orthopedics Physical exam: abnormal feet and abnormal genitalia Recommendations: Therapies to address developmental delays and follow ASAP with urology and orthopedics Formal report sent to PCP, Regional Center, and family
Tony s final high risk infant visit was one year after his third visit: Receiving regular cardiology care Receiving regular orthopedic care, status post surgery on left foot, pending surgery on right foot Receiving regular urology care, status post surgery for bilateral undescended testes Therapy on hold secondary to multiple medical needs Plan to transition to school district to address ongoing developmental delay
What happened between the third and fourth visit that influenced Tony s case??
CASE MANAGEMENT INVOLVEMENT IN COORDINATING TONY S MEDICAL CARE!
Multiple phone calls to PCP and identifying a point person in the PCP s office to assist with coordination Multiple phone calls to CCS Multiple phone calls to specialists Multiple calls to family and letter sent specifying each specialist and contact information Education with family about importance of advocacy and navigation of health care system
Cynthia is a 21y.o. with chronic disabilities She has complex, multiple specialty needs. She requires mod/max assist for her ADL s. She has had relationships with her health care providers for more than 20 years. Her diagnoses are as follows: Thoracic Level Spina Bifida Latex Precautions Chiari II Malformation VP V.P. Shunt Thoracic Deformity Restrictive Lung Disease Neurogenic Bladder and Bowel Developmental Delay
Providers Involved at Discharge: Neurosurgery Orthopedics Orthotics Urology Pulmonology Gynecology
Resources Family Case Management/Specialty Nurse Primary Care Provider (Pediatrician) Medi-Cal/ CCS ( maximize CCS/ terminates at 21y.o.) SSI School/IEP (eligible for services till 22 years old. ) Regional Center (future housing) Social Services Legal Aide In Home Supportive Services National Organizations
Needs: Insurance/ Medi-Cal Adult Care Provider and Specialists (diagnosis education/treatment plan) Day Program/ Schooling Transportation DME (wheel chair, bracing, Oxygen) Soft Supplies (catheters, incontinent supplies) Legal-Medical l Power of Attorney/ Conservatorship
Transition process begins at birth: Education/Support Personal Empowerment Identification of Environmental Capacities
Conditions that need to be in place for a successful case management experience: Commitment to emotional, psychological, and physical development Identification of the people who want assistance Identification of the people who want assistance and those who don t; those who are functional vs. dysfunctional
Goal is to Inspire and Love Life If you are not expanding your emotional/psychological/physical capacity to think and dto be aware of what tis going on with yourself, you do not have the tools to accurately protect yourself from the environmental exposures. Development of emotional/psychological capacity helps organize thinking which gives clarity to follow through and the meaning of life.
Mrs. B, 77 year old active senior. Independent lives alone in mobile home. Interests are swimming, gardening and traveling. Manages all finances, bills etc independently. Drives. Health history- mild depression, low dose antidepressant. Recent surgeries- hysterectomy and cholecystectomy. Health insurance Medicare HMO SCAN Durable Power Attorney Health Care (DPAHC) & Durable Power Attorney (financial) in place and completed prior to surgery.
Memory changes / 77 83 years age Symptoms- problems with managing finances, poor dietary intake, missing medications, driving less often and getting lost, decrease in appearance, poor hygiene and poor housekeeping, loss of interest in hobbies. Medical workup frequent MD visits. it Work up for pathology. All negative except CT brain showed increase in white matter (seen in dementia)
Interventions for independence DPAHC and Financial i DPA- done Review health plan benefits for assistance in the home or any long term care policies SCAN Independent d Living i Power Homemaker aide 2 x week to help with bathing, food prep, light housekeeping Meals on Wheels- one hot meal / cold meal per day No more driving- family help with all transportation Agencies can hire someone if no family $15 / hour 4 hour min. per day / 8 hour min. per week
Automatic pill dispenser (see picture) Medical Alert ( see picture) Family helping with all finances, bills, and all medication ordering, etc. Home assessment for safety- remove rugs, proper lighting, grab bars in bath/shower, non-skid tub, bath chair, hand-held held shower head. Attempt assisted living (AL) placement- Mrs. B refused MOST IMPORTANT- DPAHC and DPA Financial
83 years LIFE EVENT CHANGE Fell at home- fractured pelvis- no surgery needed, only pain management and slow ambulation. Brief hospital stay, then SNF for rehabilitation Placement in small Board / Care (B/C) ( 6 bed) Placement agency help to find Large B/C not appropriate, because of short term memory loss and poor safety awareness Costs- $2000 - $ 5000 ( includes all care except medication and supplies)
88 years old Life Event Change Another fall- despite lap belt, chair alarm Forgets she can t walk Fractured Hip surgery done SNF placement for rehab and permanent placement Spent down funds for B/C. Less than $2000 assets Medi-Cal for long term placement in SNF
Mrs. B will be 90 years of age May 23 rd, 2011 Average life span in SNF Assisted living 21 months Skilled nursing facility 50-60 % mortality first year Mortality-related factors and 1-year survival in nursing home residents http://www.ncbi.nlm.nih.gov/pubmed/12558718 Mrs. B spent 6 years in AL and 13 months SNF