Post Discharge Coordinator called a 77 year-old female patient post emergency department discharge for COVID and anxiety. The patient and her husband had tested positive for COVID. The patient’s husband had been admitted to the hospital and patient was living alone as their adult children live out of state. When the Post Discharge Coordinator (PDC) spoke with patient she was out of toilet paper and Depends and did not know what she was going to do. The patient was not able to drive due to her vision and her husband was in the hospital. The PDC scheduled a video emergency department follow up appointment with the Nurse Practitioner for later that day. A referral was made to the Resource Coordinator where the PDC explained the patient’s need for toilet paper and Depends. The Resource Coordinator went online and ordered the supplies for the PDC to pick up same day and deliver them to the patient.
The Resource Coordinator spoke with the patient and patient’s daughter about needs going forward while her husband was in the hospital/rehab. One concern from the patient’s daughter was for the patient to be examined as the family would like to know if she is recovering well from COVID. The Resource Coordinator sent a referral for a home Transitional Care Management visit. Since patient had no family close by, the Resource Coordinator suggested hiring a home health aide. The patient and her family were interested in the idea. The Resource Coordinator provided the family with three different private pay agencies and received follow up that they had been in contact with one of the agencies and most likely would be hiring them.
Resource Coordinator became involved with this 46 year-old male patient for some in home health equipment the patient was needing. The patient was being taken daily to the hospital for Dialysis and to and from all his medical appointments by his wife. The patient had spent a short time in a rehab facility that didn’t work for him. While at home the patient’s stump, where he had just had surgery, became infected and he had to return to the hospital. The Resource Coordinator continued to make contact with the patient’s wife in regard to the in-home health equipment needed as there were some issues with his account that the Resource Coordinator had to work through. While all these things were happening, the Resource Coordinator developed a new resource and relationship with the Lafayette Regional Rehabilitation Hospital. Upon learning more about this facility and their success rate, the Resource Coordinator, with the Primary Care Physician staff, and Care Navigation staff all agreed this would be a good fit for the patient.
Following a procedure to remove the infection from the patient’s stump, the Resource Coordinator spoke to the patient’s wife concerning the facility and shared with her the Occupation Therapy/Physical Therapy available for her husband, the on-site Dialysis at the facility, and the facility offered stump care and prosthetic care education not only for the patient, but for the family as well. The Resource Coordinator spoke of the quality of care the patient would receive and that this would give the patient and patient’s family a better quality of life once he leaves the facility. The Resource Coordinator connected the patient’s wife with Lafayette Regional Rehabilitation Hospital.
The patient was discharged and transported safely to the Lafayette Rehabilitation Hospital. The patient’s family are pleased he will be able to receive all the care he needs under one roof.
Patient is a 64-year-old male, using a wheelchair for mobility, who had been receiving a Veteran’s Pension for several years. He has a history of atherosclerosis of artery of lower extremity, hypertension, arthritis of the knee, chronic pain, morbid obesity, benign prostatic hyperplasia, and arthralgia of both knees, and had never been able to secure a statement regarding the amount of the pension. This kept the patient from receiving assistance from community resources. Patient was approved for an Aged and Disabled Waiver to receive in home services through Life Stream Services (Area 6 on aging) but has not been able to get Medicaid in place to receive those services due to his inability to get the statement from Veterans Administration.
The Resource Coordinator contacted a Veteran’s Administration Social Worker to get directions on who or how to secure a pension statement. The Resource Coordinator contacted the patient and called the number provided by the Social Worker on a conference call and was able to request the document. The document was emailed to the Resource Coordinator who sent it to Medicaid with the patient’s other required documentation.
The patient was approved for Medicaid in two weeks. Patient stated he was absolutely amazed by this as he has not been able to get that document since he started receiving the pension several years ago. Patient states this will change his life in many ways and was very thankful.
Emergency Department Patient Admitting to Rehab
This 52 year-old male patient has a history of alcohol abuse, cocaine use, and noncompliance with medical treatment. He presented to the Emergency Department (ED) for another episode of acute pancreatitis in July. The Post Discharge Coordinator left him a voicemail message after being discharged for a return call. He contacted the Post Discharge Coordinator to inform her that he was going to a medical detox inpatient rehab unit and wanted to make sure his primary care physician was made aware that he was ready to get help.
The patient had 37 ED visits in 2019, some resulting in admissions, and 11 visits from January through July 2020. He would answer the phone every once in a while, when the Post Discharge Coordinator would outreach. However, things turned around following patient’s detox. He completed an appointment with his primary care physician who learned the patient was transitioning to rehab and them to a sober living outpatient treatment. Due to the multiple transitions and the patient’s expressed appreciation on numerous occasions for the Post Discharge calls, we called the patient weekly to make sure he was having a smooth transition.
Some of the changes the patient has made since he has been sober and with the support from his care team includes:
The patient stated “[The Post Discharge Coordinator] is absolutely awesome and I really enjoy talking to her. We have developed a great bond” and “I feel like a new patient.”
This patient has not had any utilization for the past two months.
The Primary Care Navigator met the patient after a warm hand off in the Primary Care Provider’s office. Patient has a leg amputation with chronic wounds on his non-affected leg that were further impacting his mobility. He was receiving Home Care and Outpatient Wound Clinic care along with IV antibiotic therapy. The Primary Care Provider mentioned that if the IV antibiotic didn’t work “this time” he may need to discuss another amputation.
The patient disclosed that his finances were stretched. He had no money at the end of the month and was accruing medical debt. The Primary Care Navigator (PCN) made a referral to a resource coordinator to assist with food needs and any available financial assistance. Lifestream was involved for potential home health aide assistance and delivered meals.
A referral was made to the Home Health Agency. They stated that his floorboards were reinforced with plywood making it an unsafe environment for him. Senior housing was discussed. His largest obstacle was having no funds left for the move. The Primary Care Navigator contacted Bethel UMC. They had partial funds to assist with a large portion of the move which would provide a safe affordable senior apartment. He would be able to have funds remaining with this move. Private benefactors aided in the remainder of the moving costs. The PCN was able to assist with wound and home environment assessment prior to the move.
The patient is reportedly very content and pleased with his new home which provides a safe environment with level floors aiding safe mobility for an amputee along with an elevator access and a move toward financial freedom.
ED Avoidance through Home Monitoring Program
Helping Patient Dealing with Stress and Depression
Educating Patient on Disease Process
69 Year old male with a history of type II diabetes (A1c 8.6), hypertension associated with chest pain, diabetic neuropathy, history of prostate cancer and hyperlipidemia. The patient has a limited knowledge of the disease process, medications, and how diet affects disease. He was fearful of taking medications due to possible side effects. It was discovered that the patient had placed three different medications in one bottle so he was not taking his medications as prescribed. His blood pressure was high at 206/100 and he was not checking his blood sugars or blood pressure at home. The Primary Care Navigator (PCN) referred the patient to a pharmacist. He refused a referral to the dietician. The patient agreed to work with the PCN and agreed to frequent follows up in office. The patient was given medication education and frequent adjustments. Diet education focusing on diabetic diet along with low sodium education was provided. The patient started bringing his medications to every office visit for review as to how and what he was taking. He was ordered and instructed on how to monitor blood sugars. The PCN reviewed with him how to recognize signs and symptoms of high blood pressure and how to check his blood pressure at home. The PCN provided disease education on diabetes, hypertension, chest pain, diet and exercise. The patient now has a greater understanding of medication, how they work and when to take them. He no longer mixes medications and continues to check this at office visits. The patient is following a diabetic diet, counting carbohydrates, and has a good understanding of sodium in foods. He is aware of high fat foods and what to avoid. His blood sugars are now in range and he uses his glucometer and can identify out of range blood sugars. Fasting blood sugars now in the range of 90 to 120. He is checking his blood pressure at home and can identify when out of range (BP 130s/60s). He has no complaints of chest pain, headaches, blurred vision, or SOB. He has made positive changes in overall diet and health maintenance and is active in his job and gets exercise.
Tremendous Reduction in A1c
A 69 year old male was admitted for two days when he presented to the Emergency Room with hyperglycemia, a new diagnosis of diabetes, had fasting blood sugars greater than 600, and an A1c greater than 17. The patient had a history of COPD, CHF, cerebral vascular accident, and cognitive deficiencies secondary to stroke. He had limited day to day activities due to mobility concerns as well as fall safety concerns secondary to stroke.
The patient had limited education in regards to his chronic health concerns, especially COPD and CHF. He has great family support from his brother whom the patient lives with. It was determined that the patient needed fall safety training, education on all chronic disease pathways, and resources for the patient, as well as his caretaker.
The Patient Care Navigator (PCN) teamed up with a pharmacist to help with insulin instruction and titration, and a dietitian to help with meal planning and nutritional instruction. The PCN completed education on all three chronic disease states – DM, COPD, and CHF with the patient and provided Zones information with recommendations for outreach which the patient and family had never had before. A resource referral and assessment was made for safety equipment, and assessment regarding caretaker burnout and supports available. Options for fall safety home assessment and physical strengthening were provided and the PCN reviewed stroke prevention and assessed for ongoing PT, OT, and ST needs.
In three months, the patient’s A1c improved from greater than 17 to 7.4. The patient and his brother endorse a better understanding of how to manage diabetes day to day as this was an entirely new diagnoses for them. They also possess an increased understanding of other chronic health conditions of COPD and CHF including symptom awareness and response/outreach for these symptoms. The patient and his brother have a contact in office to reach out to for further concerns and needs and now have more options for ongoing support, resources, and daily interventions that they can self-manage at home.
Patient with Diabetes and Depression
This 35 year old female patient was initially diagnosed with diabetes in August with a starting A1c of 14.2. She was morbidly obese with a starting weight of 292 lbs and a BMI of 45%. The patient had increased depression with no family support to help manage the new chronic health diagnosis, had limited resources for medication cost, a lack of information and education regarding her new primary diagnosis, and had anxiety and fear regarding the self-administration of insulin.
The Primary Care Navigator (PCN) provided diabetes education as well as education on how to inject insulin with a demonstration and teach back using toolbox resources. The PCN had weekly follow up and communication with the patient regarding blood sugar readings and adjustments in medication between the patient, PCN, PCP, and pharmacist. The PCN referred the patient to team resources including pharmacist, dietician, and LCSW. A referral was made to medication assistance regarding the cost of medications and the patient had ongoing support from the whole team regarding the impact of the health condition on the patient’s emotional health.
In five months, the patient’s A1c improved from 14.2 to 6.1 The patient has started on a weight loss path and is down 1.8% and over 1% on her BMI. The patient feels more confident with food choices and her ability to manage this chronic health concern. She is able to independently give herself insulin injections and has learned coping skills to manage her symptoms of anxiety and depression. PHQ 9 score improved from 13 to a 6 and GAD 7 score improved from a 7 to a 5.
The patient smiled for the first time during Care Navigation appointment when given new of the low A1c. Every other face to face encounter, patient was tearful and demonstrating negative self talk. She now has a more positive mindset regarding herself and her health.
New Diabetes Diagnosis
Twenty year old female was inpatient after being found unresponsive at home. She was admitted to the hospital in ARF with a new diagnosis of T1DM. Patient had been having symptoms for about a year prior to this incident but was not seeing a physician. She outgrew her pediatrician and had not established care with a PCP. She was sent home with a temporary dialysis catheter, outpatient dialysis chair, some instructions for insulin management and diet, and a referral for a new PCP 12 days after discharge from the hospital.
The patient and her mother were not provided with contact information to manage diabetes between inpatient stay and start of care date for patient. Patient’s mother called APC to try to get patient’s PCP appointment moved up due to patient having low blood sugars (40’s to 50’s at times during the night). Patient’s mother was frantic on the phone when she talked to the call center. The call center asked the Resource Coordinator if she could call the mother to calm her down. The patient and mother had questions about insulin administration, hypoglycemia management, severe depression, and anxiety of patient, dietary concerns for her renal disease and diabetes.
The Resource Coordinator recognized the need for immediate intervention and sent a referral to the Patient Care Navigator (PCN). The PCN reviewed patient’s chart and had a conference with the PCP who agreed to see the patient to establish care within 24 hours. The PCN called the patient and caregiver to obtain home blood sugars since the hospital discharge and sent them to the PCP. The PCP made adjustments to the insulin to prevent low blood sugars.
Endocrinology is managing patient’s diabetes now. She has an insulin pump and continuous glucose meter. Her blood sugars are more stable. Renal failure has been resolved and the patient is no longer on dialysis and has had her dialysis catheter removed. Her depression and anxiety are managed and she continues to go to counseling.
Spouse Caring for Stroke Patient
68 Year old male had a stroke in May. He was transferred from acute rehab to a skilled nursing facility in July. He was discharged from skill nursing to home in September.
On initial call, the patient’s wife told the Discharge Coordinator that she was overwhelmed and unable to care for the patient at home. Patient was not able to walk and patient’s wife stated that it took two people to transfer him from the bed to the wheelchair. Patient’s wife was not sure how much longer she would be able to physically help with transfers. Patient’s wife works full time and has been missing work to care for patient.
Patient has VA benefits. The skilled nursing facility coordinated with VA to have VA come out and evaluate patient for caregiver hours and deliver a hospital bed upon discharge from the skilled nursing facility. VA had not been out to the home despite multiple calls from wife. Home health nurse had been out to assess patient and called the VA after seeing patient. Wife has no way to transport patient to and from appointments, as she is unable to get patient in and out of a car.
The Discharge Coordinator called post-acute case manager and explained the situation. She called the nursing facility that patient was discharged from. A social worker from the facility called and talked to the patient’s wife. Patient was readmitted to skilled nursing facility the next day. Patient is receiving the therapy he needs at the skilled nursing facility.
Dramatic Reduction in ED Visits
Patient was identified as a frequent emergency department (ED) visitor with 49 emergency room and short stay admissions over two years. The patient suffered from migraines and migraine type symptoms. Depression/anxiety and stressors including family dynamics influenced migraine management.
Patient wasn’t aware of other options to seek care for migraines outside of the emergency department. Patient’s access and level of comfort with behavioral health providers fluctuated.
The patient enrolled in Care Navigation. Patient was educated on other options for access to care such as same day primary care physician appointments. A review of migraine triggers and a plan of action was created. The patient was linked to a behavioral specialist and was educated regarding health concerns with a focus on building a healthy lifestyle.
Since enrollment into the Care Navigation program, the patient has experienced a 65% reduction in emergency department visits. The patient sees a primary care navigator at the primary care provider’s office every other month and has improved confidence in managing health.
Chronic Chest Pain
53 Year old female with a history of vitamin B12 deficiency, thyroid disease, obsessive compulsive disorder, anxiety with depression, gastric bypass in 1999, and Van Willebrand disease.
Patient was admitted in early September for what was thought to be an ST elevation myocardial infarction involving the right coronary artery. Patient had emergent cardiac cath that revealed no obstructive blockages. Cardiology determined her signs and symptoms were related to coronary vaso spasms. Patient was discharged two days later. Patient presented again to the ED two days after discharge with chest pain. During a call to the patient, she revealed to the Discharge Coordinator that she did not receive any discharge instructions from either visit to the hospital. The patient was feeling stressed and felt like she did not have a good understanding of what was going on and why the chest pain continued to occur. She felt like she was not treated well at the hospital. The patient had a follow-up appointment scheduled for mid-September with the nurse practitioner in the cardiology office.
The Discharge Coordinator called the cardiology office to see if the patient could get an earlier appointment. She shared with the office concerns of possible readmittance due to the lack of understanding of discharge instructions and disease state. The Discharge Coordinator connected the patient with an LPN to make additional follow-up calls with the patient after appointment with Cardiology to ensure patient got the care that she needed, assess her understanding of what was discussed during her appointment, and assess for any further needs.
Patient’s appointment with the nurse practitioner was made that same day the Discharge Coordinator called the cardiology office. Patient received a diagnoses of prinzmetal angina, which is when the coronary arteries spasm, thus causing the heart muscle to be deprived of its blood supply (in females, this can mimic a heart attack). When the nurse practitioner and patient met, medications were adjusted, education was provided on the signs and symptoms to watch for, and education was provided with how and when the patient should take her blood pressure.
On a follow-up call with patient three days after meeting with nurse practitioner, the patient stated that she was doing great and was thankful that the Discharge Coordinator cared and got her seen by the cardiology office. The patient reports she now has an understanding of what is going on and will keep her appointment with cardiology.
Non-Compliant Diabetic Suffers from Drowsiness and Leg Pain
53 Year old male patient has a history of uncontrolled type II diabetes – A1c of 11.2; hypertension – blood pressure 162/90; hyperlipidemia – cholesterol 216, triglyceride 213; and diabetic retinopathy without macular edema. The patient wants his blood sugars to be better but has poor medication adherence and is not motivated to make changes or confident that he can do it. After the initial PCN (Primary Care Navigator) visit, patient chooses not to continue in the Care Navigation program unless his wife participates and tells him what he needs to know because of time constraints due to his job, which involves much traveling.
The patient’s wife joins the Care Navigation program for her own health issues, but the patient still decides not to participate. Six months later, the patient has changed his mind, meets with the PCN, and is referred to the clinical Pharmacist. The patient becomes more compliant with insulin injections. Patient is also more compliant with GLP1 after switching from Trulicity to Victoza, as he does not like the auto-inject pen. The patient is given a new meter to sync by phone so he, the Care Navigation team, and his primary care physican can more easily review his blood sugars. Patient complains of leg pain and is subsequently diagnosed with diabetic peripheral neuropathy and treated with medication. The patient mentions to PCN that he sometimes nods off while driving for work. The patient is educated about eating healthy snacks throughout the day and discovers that talking on the phone helps him to stay awake while driving. The schedule for taking certain medication is also adjusted so that he has less daytime drowsiness.
Seventeen months after the initial PCN visit, patient’s A1c is down to 8.0, his blood pressure is down to 128/78, and lipid level is improved – cholesterol 123, triglyceride 145. Patient’s retinopathy remains the same. He no longer has leg pain from diabetic neuropathy, no longer feels drowsy while driving, and his medication adherence is now good.
Housing Issues Impacting Patient’s Health
The Resource Coordinator (RC) first spoke to this patient in early July 2018, when she appeared on the emergency department discharge list. At that time, the RC connected her with the summer energy assistance program and assisted getting the patient connected to a behavioral health therapist. The patient, a 54 year old female, contacted the RC again in early August due to a water leak under her home and was unable to pay to have it repaired. She’d been staying at a friend’s house due to her water being turned off.
The patient has a history of type II diabetes and mental health issues, including bipolar disorder, anxiety, depression, and grief. The patient stated that she was depressed and felt defeated due to her financial situation and she had lost several close family members and was experiencing grief.
The patient seemed reluctant to attend behavioral health therapy, so the RC followed up with her and strongly encouraged her to call and schedule an appointment, which she did. After several calls, the RC was able to connect the patient with an organization called Renewable Hope through Habitat for Humanity. They were able to gather volunteers to fix the water leak under the home, in addition, they replaced some of her roof, mowed the lawn, and cleaned up around the exterior of the home. Renewable Hope also assisted the patient in completing an application to lower her water bill with the City as she had an outstanding bill of $2,000.
This assistance made it possible for the patient to move back into her home. She was feeling less hopeless and was very appreciative of the work that was done. The patient expressed relief due to the financial assistance and is meeting with the behavioral health therapist.
Depressed Diabetic Patient
This 63 year old female patient has a history of type II diabetes, hypertension 184/104 (ranged 150-160/100) and depression. The patient was non-compliant with medications and didn’t want counseling. She was tired of having to follow a diabetic diet because she felt it made no difference in her blood sugar readings.
The Primary Care Navigator had frequent contact with patient and made referrals to a pharmacist, new dietician, and behavioral health. After frequent visits and phone calls, patient’s insulin was adjusted, the new dietician had a different approach to diet management so patient had regular visits, and met with LCSW (Licensed Clinical Social Worker) for behavioral health. After 2-3 visits with LCSW, patient started to make lifestyle changes. She kept her appointments with the other disciplines and started seeing a decrease in her weight, blood sugar readings, and blood pressure. Within 5 months of the initial Behavioral Health referral, the patient was weaned off of her insulin. She lost 20 lbs and her hypertension was controlled.
Patient has made major lifestyle changes with diet, exercise, and daily routines. She follows a plant-based diet, is in a nutrition support group, and is talking about getting a certification to help others make lifestyle changes to assist with better diabetes control.
Within four months, the patient’s A1c dropped from 8.1 to 6.2.