Case Studies Group Activity

1. Case StudiesGroup Activity • Each group will receive the first slides of a case study • Each group will have about 15 min to review and answer questions • Each group will need to identify a leader and a scribe (unless facilitator scribes) • Groups will have ~10 minutes to share/report out |

2. Case Study A • 65 y/o retired/Lives with wife has AD • PMH: HTN/Stopped smoking 5 years ago • Enrolled in CM 6 months • 5 hosp. for COPD LOS 2-3 DAYS • Presents to the ER after 6pm • 10 ER visits for SOB • FEVI 26/ Oxygen 2/L per min • Has rescue kit Prednisone/Z Pack • Meds: Advair 1 inhalation bid/Provential qid/Toprol 100mg bid • C/O no energy • Pt’s wife calls CM with concerns • Husband “not right ” • Occasional confusion and restless sleep • CM assessment completed • Denies fever or abdominal pain but occasional nausea • Appetite poor, oral intake poor • Case discussed with PCP |

3. Case Study A • Uses inhaler several times throughout the day • Lost 10lbs over the last 3 months • Most recent hosp. 2 day LOS /Adm from ER/Did not start rescue kit • Not wearing Oxygen 24hrs states it doesn’t make a difference • CM meets with pt. at post discharge appt.not wearing oxygen |

4. Case Study A • What information is missing? • What is the POC for this pt? • Changes to current treatment plan ? • CM follow-up?

5. Action taken and results – Notes for Leaders (Case Study A) • Review case with PCP • Z Pack in rescue kit • Medication review • Pul. Med. Referral • Outpt. Pulmonary Rehab • Nebulizer with duoneb • Education on energy conservation • Nutrition review • Review refill history with Pharmacy • Depression evaluation • Caregiver for wife |

6. Case Study B • 70 year old female • Hs. HF EF 25%,CAD.HTN,Osteoporosis,Smoked for 30 years • Meds: Lasix 20mg qd, Ca/VitD 2 tabs qd/Lopressor 50mg bid/ASA QD/ Lisinopril 10mg qd • Pt. calls CM states she is SOB and having a hard time sleeping, wt. up 2/LBS • PCP doubles Lasix for 2 days • CM f/u pt. states she feels the same SOB, not sleeping has a cough • Pt. seen in office SOB with plus 2 ankle edema 40mg Lasix IV/Labs drawn • GFR 24 last one 50 |

7. Case Study B What are the likely next steps? What other information do you need? Design a treatment strategy... |

8. Considerations for PlanCase Study Is this HF ? Has the pt. had PFT’s BNP Pulse Qx Pulmonary evaluation CXR pt had pneumonia Antibiotic Fluids Prednisone Dexa Scan when stable Ca/VitD split doses Inhalers |

9. Case Study C • 68 yo female presents to Doctor office, productive cough with thick yellow sputum, SOB, wheezing x 3 days • BP 168/86, T 100.6, HR 102, Pulse ox 89% at rest • CXR shows LLL infiltrate • H/O osteoporosis, HTN, GERD, chronic bronchitis, tobacco abuse-2PPD x 24 yrs, quit 3 yrs ago, spouse still smokes in home • Oriented time, place and person, independent with Activities of Daily Living • Meds: Lisinopril 20 mg daily, omeprazole 10 mg daily

10. Case Study C Considerations • Can this pt be safely treated as an outpt? • What should be done with this office visit? • Design a treatment strategy with Doctor and pt • CM follow-up plan

11. POC – Case Study D • Attend Doctor appt. – prescribed antibiotic • Nebulizer tx in office – educate pt on use of nebulizer and cleaning • Check pulse ox with exercise – drops to 84%, apply 2L – increases to 92% • Contact DME vendor who can deliver oxygen and nebulizer today – will also instruct pt on use and provide f/u • Next day f/u call to pt • Schedule PFT’s • Schedule DEXA scan when stable – appropriate medications based on results • Recheck BP when stable – med adjustment and education as indicated • Offer spouse TCTP – encourage no smoking in home at very least

12. Case Study D • Referral post hosp.stay – LOS 3 days • 76 yo male with RUL pneumonia and UTI, treated with IV antibiotics. • H/O MI 2009 with stent placement, HTN, PVD, CKD stage III, COPD, migraines • No PFT’s found in chart review • D/C meds: Augmentin 875/125 mg – 1 tablet Q 12 hrs x 5 days, Proair inhaler – 1 to 2 puffs prn, metoprolol 25 mg – BID, ASA 81 mg OD, Cozaar 25mg OD, Advil migraine 2 tabs daily prn. • CM has tried to contact pt for 2 days without success.

13. Case Study D Considerations • How would you try to contact pt? • What other information could you use?

14. POC – Case Study D • Contact case manager from discharging facility. Pt left with daughter. • Pt staying with daughter. • Pt debilitated – arrange PT/OT • Schedule Doctor appt • Repeat urine when antibiotics completed • What is pt goal? • Explore in home care options. • Schedule PFT’s – stratify and develop POC with PCP based on results, rescue kit. • Medication reconciliation indicates was on Lasix 20 mg BID and K+ 10 meq prior to admission – review with PCP • Discuss use of Advil with CKD, educate on CKD

15. Case Study E • 87 yo male admitted to local hospital for 3rd time in past 12 months with COPD exacerbation. This admission complication of pneumonia requiring intubation. Treated with IV antibiotics and steroids. • PFT’s done 1 yr ago show FEV1 of 28% • H/O DM, tobacco abuse – has decreased to 6-8 cigs/day from 2 PPD. HTN, PVD, CAD • FBS 250-300, 2 hrs PP 190 – 320 since d/c from hospital • Current meds: metformin 500 mg BID, Glucotrol XL 20 mg OD, Lisinopril 20 mg OD, metoprolol 25 mg BID, ASA 81 mg OD, Combivent every 4 hrs as needed, Advair 250/50mg 1 puff twice daily, oxygen 3L/min continuous • Pt recently widowed, now lives alone. Admits to severe weakness, cough with yellow sputum, unable to perform ADL’s, eating microwave dinners, sleeping in recliner. States “I’m tired of living like this”.

16. Case Study E Considerations • What would you assess first? • What other information is needed? • Can meds be optimized?

17. POC - Case Study E • Dexa Scan • Alternate living arrangements considered – assisted living, PCH • Encourage TCTP, educate on benefits of quitting even at this time of life • Referral for community resources if pt desires to remain in own home • Assess depression, support group, grief counseling • Family involvement • Address Advanced Illness – Living Will, POLST