Panel Participants:Elizabeth Buss, RN, BSNLisa Stablein, RN, BSNJackie Touch, MSN, RN-BC, CPN, CCM

At the end of this presentation, the participant will be able to:

Identify barriers to efficient case management of the complex clienta age e t o t e co p e c e tIdentify strategies to facilitate effective case managementeffective case management

Tony is an ex-term infant who had a complex neonatal course secondary to congenital heart disease. He is b f ll d h h h k f f ll ( )being followed in the high risk infant follow up (HRIF) program.

Recommended follow up after NICU discharge:Recommended follow up after NICU discharge: pediatrician, cardiologist, several other specialists

Funding source: CCS and managed care Medi-CalClient of Regional CenterRecommendations from first visit: therapies to

address developmental delays and follow up withaddress 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 cardiologyg g p gyReceiving therapy twice a month (mother was unable to specify what type of therapyN i i f ll i h h i liNot receiving any follow up with other specialists as recommendedPhysical exam revealed abnormalities of feet andPhysical exam revealed abnormalities of feet and ankles: Orthopedic consult recommendedRecommended follow up with specialists from first i it ( ti d lvisit (genetics and urology

Formal report sent to PCP, Regional Center and familyy

Tony returned for a third high risk infant follow up visit approximately 8-9 months after his second pp yvisit. Regular follow up with cardiologistPhysical therapy once a weekPhysical therapy once a weekNo visits yet with urology, genetics, or orthopedicsPhysical exam: abnormal feet and abnormal genitaliaR d i Th i ddRecommendations: Therapies to address developmental delays and follow ASAP with urology and orthopedicsFormal report sent to PCP, Regional Center, and family

Tony’s final high risk infant visit was one year after his third visit:his third visit:Receiving regular cardiology careReceiving regular orthopedic care, status post surgery on left foot pending surgery on right footsurgery on left foot, pending surgery on right footReceiving regular urology care, status post surgery for bilateral undescended testesTherapy on hold secondary to multiple medical needsPlan to transition to school district to address ongoing developmental delay

What happened between the third and fourth visit that influenced Tony’s case??

CASECASE MANAGEMENT

INVOLVEMENT IN COORDINATING TONY’S MEDICAL

CARE!CARE!

Multiple phone calls to PCP and identifying a point person in theidentifying a point person in the PCP’s office to assist with coordinationMultiple phone calls to CCSMultiple phone calls to specialistsMultiple calls to family and letterMultiple calls to family and letter sent specifying each specialist and contact informationEducation with family about importance of advocacy and navigation of health care systemnavigation 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 BifidaThoracic Level Spina BifidaLatex PrecautionsChiari II MalformationV P Sh tV.P. ShuntThoracic DeformityRestrictive Lung DiseasegNeurogenic Bladder and BowelDevelopmental Delay

Providers Involved at Discharge:Discharge:

NeurosurgerygOrthopedicsOrthoticsU lUrologyPulmonologyGynecologyGynecology

ResourcesFamilyC S lCase Management/Specialty NursePrimary Care Provider (Pediatrician)Medi-Cal/ CCS ( maximize CCS/ terminates atMedi Cal/ CCS ( maximize CCS/ terminates at 21y.o.)SSI School/IEP (eligible for services till 22 years old )School/IEP (eligible for services till 22 years old. )Regional Center (future housing)Social ServicesLegal AideIn Home Supportive ServicesNational OrganizationsNational Organizations

Needs:Insurance/ Medi-CalAdult Care Provider and Specialists (diagnosis education/treatment plan)education/treatment plan)Day Program/ SchoolingTransportationpDME (wheel chair, bracing, Oxygen)Soft Supplies (catheters, incontinent supplies)

l d l f hLegal-Medical 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:successful case management experience:

Commitment to emotional, psychological, and physical development

Identification of the people who want assistanceIdentification 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

d t b f h t i i ith lfand to be aware of what is 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 tohelps 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 doseHealth history- mild depression, low dose antidepressant. Recent surgeries- hysterectomy and cholecystectomy.Health insurance Medicare – HMO – SCANDurable Power Attorney Health Care (DPAHC)Durable Power Attorney Health Care (DPAHC)& Durable Power Attorney (financial) in place and completed prior to surgery.

Memory changes / 77 – 83 years ageSymptoms- problems with managing financesSymptoms problems with managing finances, poor dietary intake, missing medications, driving less often and getting lost, decrease in appearance, poor hygiene and poor housekeeping loss ofpoor hygiene and poor housekeeping, loss of interest inhobbies. M di l k f t MD i it W k fMedical workup – frequent MD visits. Work up for pathology. All negative except CT brain showed increase in white matter (seen in dementia)

Interventions for independence

DPAHC d Fi i l DPA dDPAHC and Financial DPA- doneReview health plan benefits for assistance in the home or any long term care policiesSCAN I d d Li i PSCAN – Independent Living PowerHomemaker aide 2 x week to help with bathing, food prep, light housekeepingM l Wh l h l / ld l dMeals on Wheels- one hot meal / cold meal per dayNo more driving- family help with all transportationA i hi if f il $15 / hAgencies can hire someone if no family $15 / hour4 hour min. per day / 8 hour min. per week

Automatic pill dispenser (see picture)Medical Alert ( see picture)Medical Alert ( see picture)Family helping with all finances, bills, and all medication ordering, etc.gHome assessment for safety- remove rugs, proper lighting, grab bars in bath/shower, non-skid tub, bath chair hand held shower headbath chair, hand-held shower head.Attempt assisted living (AL) placement- Mrs. B refusedMOST IMPORTANT- DPAHC and DPA Financial

83 years LIFE EVENT CHANGEFell at home- fractured pelvis- no surgery neededFell at home fractured pelvis no surgery needed, only pain management and slow ambulation. Brief hospital stay, then SNF for rehabilitationPlacement in small Board / Care (B/C) ( 6 bed)Placement in small Board / Care (B/C) ( 6 bed)Placement agency help to findLarge B/C not appropriate, because of short term memory loss and poor safety awarenessCosts- $2000 - $ 5000 ( includes all care except medication and supplies)pp )

88 years old Life Event ChangeAnother fall despite lap belt chair alarmAnother fall- despite lap belt, chair alarmForgets she can’t walkFractured Hip – surgery done p g ySNF placement for rehab and permanentplacementSpent down funds for B/C. Less than $2000 assetsMedi-Cal for long term placement in SNF

Mrs. B will be 90 years of age May 23rd, 2011Average life span in SNF Assisted living – 21 monthsSkilled nursing facility 50 60 % mortality first yearSkilled nursing facility – 50 -60 % mortality first year Mortality-related factors and 1-year survival in nursing home residentshttp://www.ncbi.nlm.nih.gov/pubmed/12558718Mrs. B spent 6 years in AL and 13 months SNF