Risk Stratification & Intervention Follow Up Care for High Risk Patients Mary Beth Byrnes, MSN, RN.
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Risk Stratification & Intervention Follow Up Care for High Risk Patients Mary Beth Byrnes, MSN, RN
Transcript of Risk Stratification & Intervention Follow Up Care for High Risk Patients Mary Beth Byrnes, MSN, RN.
Risk Stratification & Intervention
Follow Up Care for High Risk Patients
Mary Beth Byrnes, MSN, RN
CARE MANAGEMENT PROCESS
IdentifyStratifyPrioritize
Highest risk patients through systematic risk stratification process
Intervention
Evidence Based GuidelinesEstablish Goals & ObjectivesEstablish Interactive Care Plans (SM)Multi-disciplinary Care TeamFocused on Medical, Behavioral, Socio-Economic Conditions/Barriers, Utilization
EvaluationOngoing & revised according to outcomesSystematic measurement, testing & analysisOutcome is effective, efficient, & improves quality
Identify High Risk
Planned Care at Every Visit Risk Assessment Chart Alerts
Registry Reports Notification from Hospital Admission &
Discharge Notification Self-Reporting
Risk Stratification Age Co-existing Health Conditions Number of Medications Functional Deficits Non-adherence to treatment plan Self-Care & Knowledge Deficits Socio-Economic Issues Support System Utilization
Depression Risk Factors Age Co-Morbidities Number of Medications Significant Loss - Spouse, other significant family member, pet Family Care Giver (Spouse or other generational dependent) Social Isolation/Absence of Social Support Fatigue/Sleep Disturbance Chronic Pain Functional Disability Current Alcohol/Substance Abuse Disorder Psychosocial Causes
Cognitive Distortions Chronic Stress Poor Self-Health Rating
Risk Factors for Falls
Age (>80 Years of Age) History of Falls Gait Dysfunction Balance Dysfunction Use of Assistive Devices Visual Deficit Medications (Hypotensive, CNS Suppressants) Arthritis/Chronic Pain Diarrhea/Urinary Frequency Impaired ADL’s Depression Cognitive Impairment
Cumulative Risk
0 – 1 Risk Factors – Seniors have a 27% chance of a fall each year
>4 Risk Factors – Seniors chance of a fall increases to 78% each year
Tinetti: 1998
Instrumental Activities of Daily Living - IADL
Interventions
Evidence Based Guidelines Functional Deficits Knowledge Deficits Socio-economic Issues Barriers to Achieving Goals Support System
High Risk Follow Up
Follow Up Date & Method Agreed Upon Task List with Scheduled Reminder
Identify Goals Met – Unmet Identify Barriers to Unmet Goals Revise Plan Set Next Follow Up
Case Study
85 Year Old Male Hypertension on 1 medication Active and Working until 02/2011
Fell on ice injuring ribs (1st Fall) Hospitalized for abdominal pain with subsequent
cholecystectomy SNF
Severe Depression – Short Time in Mental Health System 02/2011 to 01/2012
Fell 3 more times – Out of State/County Fracture Hip (01/2012) Fell at Home 5 weeks after discharge (5th Fall) Readmitted surgical repair wound dehiscence
Did not know family members until 01/2012
Low
Goals & Barriers
Self-Management Goals Increase Physical Activity Increase Self-Care Activities
Barriers Difficulty Dealing with Functional Loss Inability to Recognize Depression Inability to Recognize Need for PT
Interventions Inpatient & Outpatient PT/OT Home Care
Evaluation of Home Environment – Fall Prevention
Medication & Psychiatric Counseling Respite Care – 1 Week Ongoing Outreach – Patient & Wife Encourage Participating in ADL’s and
Movement Transitional Care Nurse
Questions?
