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Transition of Care Case Study
Mr. Stanley Londborg is a 65-year-old man with a long-standing history of a seizure disorder. He also has hypertension (high blood pressure) and chronic obstructive pulmonary disease (COPD). He is no stranger to the hospital because of his health issues. At home, he takes a number of medications, including three for his COPD and three — levetiracetam, lamotrigine, and valproate sodium — to help control his seizures. Mr. Londborg lives in a second-floor apartment with his 70 year-old wife, who has early stage Alzheimers, and his two children reside in other states. His primary insurance is Medicare.
Mr. Londborg came to the emergency department (ED) last week because he was wheezing and having trouble breathing. The physician in the ED conducted a physical examination that yielded signs of an acute worsening of his COPD, which is known as COPD exacerbation. (In many cases, COPD exacerbation is the result of a relatively mild respiratory tract infection, but could be due to something more serious, such as pneumonia.)
The physician in the ED ordered a chest x-ray, which did not show any signs of pneumonia. He admitted Mr. Londborg to the hospital for treatment of acute COPD exacerbation, resulting from a relatively mild respiratory tract infection. Before leaving the ED, Mr. Londborg also underwent routine blood work, which showed an elevation in his creatinine, a sign that his kidneys were being forced to work harder due to his infection.
On the medical floor, the care team treated Mr. Londborg with oral steroids and inhaled bronchodilators (standard medical therapy for his condition), which resulted in a gradual improvement in his respiratory symptoms. Nurses also gave him IV fluids for the issue with his kidneys, which slowly resolved.
But on his third morning in the hospital, Mr. Londborg complained to the intern (a first-year resident) on the care team about acute pain in his left leg. This symptom, potentially indicating deep venous thrombosis (a blood clot in his leg commonly known as DVT), prompted the team to order an ultrasound of Mr. Londborg’s lower extremities. (A primary concern with DVT is that blood clots in the legs may dislodge and travel to the lungs, causing a pulmonary embolism, which could be deadly.) The ultrasound, unfortunately, confirmed the presence of a blood clot in Mr. Londborg’s left calf. Due to his impaired kidney function, treatment for the blood clot required him to remain in the hospital on IV medication.
At 10 PM on his eighth day in the hospital, a member of the environmental services (also known as housekeeping) staff found Mr. Londborg on the floor of his room. She immediately alerted the nurses on the ward. The nurses noted seizure activity and called the overnight medical team to Mr. Londborg’s bedside. The team responded quickly and gave him intravenous medication that stopped his seizure.
Because no one witnessed his fall and seizure, Mr. Londborg underwent an emergent CT scan of his head to check for any sign of bleeding. In addition to a small bleed in his brain, he had traumatic fractures to his right hip and wrist. He has a persistent headache, but appears to be clear in his speech and thought. He is not able to walk and will not be able to do so for 2-4 weeks. He can feed himself soft food, but is not able to cut food or manage any activities with his right hand due to his cast. His pain is adequately controlled with pain medication every four hours. Mr. Londborg is now medically stable and will be discharged from the hospital tomorrow.
Case study adapted from:
- What Level of Care and care setting does Mr. L require upon discharge and why? In other words, what is the appropriate setting for Mr. L following his discharge from the hospital and why [Note that the why is very important here—what indicators are there that he requires the level of care & care setting that you propose? In other words, back up your answer.)? Specifically discuss whether Mr. L 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 Mr. L to his 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 coordination of care—what needs to be in place for him to move settings and what services will the CM need to coordinate?]
- Discuss at least three functional issues (including ADL issues) that must be resolved before Mr. L can go home. [Hint: Discuss does not mean list.]
- Discuss at least three psychosocial issues that must be addressed before Mr. L can go home.
- Discuss at least three actions that the case manager can take to increase the chance that Mr. L can go home AND that he 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 (also an attachment). Fill out the following form as completely as you can based on the information that you have—leave blank what you don’t know. (we don’t know what level of pain this client is in so don’t put anything in there!) [Again, if you don’t know what a term means, look it up. Finding information is a key competency for a case manager.]
Universal Transfer Form
DNR: ☐Yes ☐No
Reason for Transfer: _____________________________________________________________________________________
Clinical Summary: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mental Status at Discharge:
☐Alert, oriented, follows instructions
☐Alert, disoriented, but can follow simple instructions
☐Alert, disoriented, but cannot follow simple instructions
☐Not alert
☐ Numeric Pain Score: ☐1☐ 2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 Location______________________
Functional Status at Discharge:
☐Ambulates independently
☐Ambulates with assistance
☐Ambulates with assistive device
☐Non-Ambulatory
Medications administered today with time: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Isolation/ Precaution: ☐N/A ☐MRS ☐VRE ☐C-Diff ☐Other____________________________________________________
Communication Interpreter Required ☐Yes ☐No
Primary Language: _________________________ Able to: ☐Understand ☐Speak ☐Read ☐Write
Secondary Language: ________________________Able to: ☐Understand ☐Speak ☐Read ☐Write☐ N/A
Aphasia: ☐Expressive ☐Receptive.
Sign language use: ☐Yes ☐No
Devices/ Special Treatments:
☐N/A
☐V/PICC line/Portacath
☐Pacemaker
☐Foley Catheter
☐Internal Defibrillator
☐TPN
Other:___________________
At Risk Alerts:
☐N/A
☐Pain
☐Seizure
☐Falls
☐Pressure Ulcer
☐Bleeding
☐Aspiration
☐Wanderer
☐Elopement
Limited/non-weight bearing ☐Left ☐Right ☐Other: ______________________
Equipment Needed:
☐Walker Cane
☐W/C
☐Brace
☐Specialty Mattress
☐Wound VAC
☐N/A
Weight Bearing Status:
☐Non-weight ☐ L ☐R
☐Partial weight ☐L ☐R
☐Full weight ☐L ☐R
☐Amputee
☐Prosthesis use
☐N/A
Mobility:
Upper extremities ☐Normal ☐Impaired:___________________________________________
Lower extremities ☐Normal ☐Impaired:_ _________________________________________
Activities of Daily Living: (mark I=independent; D=dependent; A=needs assistance) _____ Bathing _____ Toileting/Transfers _____ Dressing _____ Ambulation _____ Eating
Continence:
Continent Bowel ☐ Bladder ☐
Occasionally Incontinent Bowel ☐ Bladder ☐
Incontinent Bowel ☐ Bladder ☐
Vision:
☐Sees Adequately
☐Impaired – sees large print but not regular print.
☐Moderately impaired – limited vision cannot see headlines.
☐ Severely impaired – no vision or only sees light, color shapes
☐ Uses Visual Aid Type:______________________________
Last bowel movement: Date: / /
Catheter last changed:☐N/A Date: / /
Auditory:
☐Hears adequately
☐Minimal Difficulty
☐Intermittently Impaired
☐Highly Impaired
☐Uses Auditory Aid Type: _______________________
Needs assistance with feeding: ☐Yes ☐No Trouble swallowing: ☐Yes ☐No
| Value | Points | Value | Points | ||
| 1) Level of Care and care setting AND WHY | 7 | 4) 3 Psychosocial Issues | 8 | ||
| 2) Resources | 7 | 5) 3 Preventative CM Actions | 8 | ||
| 2) Care Coordination | 7 | 6) Transfer form matches Case | 10 | ||
| 3) 3 Functional Issues, must include ADLs | 8 | 7) Writing, organization, professionalism | 5 | ||
| Total points=60 | TOTAL |
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