Case Study- Case Management

Description

Mrs. Helen Stanley is an 84-year-old woman with current osteoporosis, lumbar compression fractures, and chronic pain.  She also has Giant Cell Arteritis (GCA)/Polymayalgia rheumatica (PMR)—treated with steroids since 2001—and a colo-vesticular fistula since 2002.  She also has diabetes, COPD and hypothyroidism, all controlled with multiple medications.  She also suffers from notable depression since the death of her spouse 5 years ago.   Her medications are: • Metoprolol   SR 25 mg qd          • Furosemide 80 mg qd   • KCl 80 mEq qd                           • Prednisone 10 mg qd   • Alendronate 70 mg qweek         • Calcitonin NS 200 IU qd   • Ca/D 500/200 TID                      • Morphine SR 30 mg BID   • Morphine IR 5 mg q4h prn         • NPH   insulin18   • Mirtazapine 15 mg qhs               • Warfarin 2mg qhs   • Senna 2 tabs qhs                       • Colace 100 mg BID   • L-thyroxine 50 mcg qd                • Ranitidine 150 mg qd   • Albuterol nebs                             • Ipratropium MDIqAM/12 qPM   Mrs. Stanley lives in a second-floor apartment by herself, and all three of her children have passed on.  She does not drive and is socially isolated.  Her primary insurance is Medicare. Mrs. Stanley has an extensive history of hospitalization.  In the past five years, she has been hospitalized for hypotension, congestive heart failure, severe UTI, pain management due to compression fractures in her lower back, symptomatic uterine prolapse (spontaneously resolved), and COPD exacerbation.  Two months ago, Mrs. Stanley had minor trauma caused by sitting down abruptly on the commode.  This resulted in excruciating low back pain the following day.  She was hospitalized for pain control, and no new fractures were found.  She was discharged to home. Unfortunately, her functional status steadily worsened along with her back pain, and she was readmitted to the hospital for pain management and consideration of minimally invasive spinal surgery (vertebroplasty).  She experienced delirium and respiratory depression on morphine. A fentanyl PCA/patch was tried with some relief. After extensive discussion with the radiologist, it was decided that the risk of sedation outweighed the potential benefit of the procedure, and she received an epidural steroid injection instead. While her pain improved, no functional benefits were noted (for example, she is unable to sit on the toilet for a BM without severe pain).  While in the hospital, she reported pain in her vulvar/labial region and experienced vaginal bleeding. She is currently incontinent. She also experienced a notable exacerbation in her CHF and COPD symptoms, including such severe dizziness, weakness, and shortness of breath that she cannot walk independently. She is also unable to stand long enough (or safely enough) to prepare food.  Mrs. Stanley’s depression has also steadily increased.  She frequently and tearfully expresses her strong desire to return home.  She misses her own bed, her cat, and her own things around her.  She desires her plan to be discharge to home; she does not wish to discuss other options. Currently, Mrs. Stanley is as medically stable as the medical staff can make her in the hospital.  She will be discharged from the hospital tomorrow. What Level of Care and care setting does Mrs. S require upon discharge?  In other words, what is the appropriate setting for Mrs. S following her discharge from the hospital and why [Note that the why is very important here—what indicators are there that she requires the level of care & care setting that you propose?  In other words, back up your answer.)?  Specifically, discuss whether Mrs. S is a good candidate for discharge directly to home and why or why not? [Again, the why is critically important.] What resources are needed to move Mrs. S to her next level of care?  What care coordination will the case manager have to do to ensure his success at transitioning to the next level? [One of a CM’s most important functions is the coordination of care—what needs to be in place for her to move settings and what services will the CM need to coordinate?] Discuss at least three separate and distinct functional issues (including ADL issues) that must be resolved before Mrs. S can go home. Discuss at least three separate and distinct psychosocial issues that must be addressed before Mrs. S can go home. Discuss at least three actions that the case manager can take to increase the chance that Mrs. S can go home AND that she does not wind up back in the hospital.  [Think about what the role of the CM is.  Specifically, what actions would the CM take?  What services would the CM coordinate?] The following form is an example of the type of transfer form you will have to complete as a case manager.  Fill out the following form as completely as you can be based on the information that you have—leave blank what you don’t know.  [Again, if you don’t know what a term means, look it up.  Finding information is a key competency for a case manager.]