Lost in Transit Not with GEDI FOLLOW UP From the EMERGENCY DEPARTMENT

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1 Lost in Transit Not with GEDI FOLLOW UP From the EMERGENCY DEPARTMENT Alicia Salgado RN, BSN Northwestern Memorial Hospital Chicago Illinois Geriatric Emergency Department Innovations Workforce, Informatics, and Structural Enhancements GEDI-WISE TEAM August 28, 2014 Alicia Salgado, RN, BSN, TNCC Margaret (Peg) Smith RN, BSN, CEN, TNCC, TNS Disclosure The project described was supported by Grant Number 1C1CMS the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 1

2 24 72 hours Callback / day Callback Based/Derived from the four conceptual areas referred as The Four Pillars: 1. Medication (self management) 2. Dynamic patient centered record 3. Follow-up 4. Red Flags 1. Document number of attempts. 2. General questions: How are you doing after your discharge from ED? 3. Any questions regarding medications? 4. Are you having pain? 6. Do we need to take action or education about pain medications? 7. Have they filled their medications? 8. Do they have a follow up appointment? Reminder of reasons why to return to ED or just call GEDI number or PCP office nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 2

3 10-14 Day Follow up Call 1. Did they complete their follow-up appointment? 2. Any changes in their care? 3. Did they return to the ED? Day Follow up Call 4. Were they admitted and why? 5. Home health services meeting their needs? nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 3

4 Appointment Information Specialty clinic: Neuro,PMD. Follow-up Appointment Details Original print.. With: DAVID FOX Where: 676 N. SAINT CLAIR When: February 04, 2015 at 02:15 pm Comment: Arrive 15 min before appointment time. Bring picture ID and insurance card. Call office 1 day prior for changes...to avoid cancellation fees, With: SANDEEP AGGARWAL Where: 676 N. SAINT CLAIR When: February 04, 2015 at 01:45 pm Comment: Arrive 15 min before appointment time. Bring picture ID and insurance card. Call office 1 day prior for changes...to avoid cancellation fees, Appointment Information : Specialty clinic: Neuro, PMD. Follow-up Appointment Details With: DAVID FOX Where: 676 N. SAINT CLAIR New print When: February 04, 2015 at 02:15 pm With: SANDEEP AGGARWAL Where: 676 N. SAINT CLAIR New print When: February 04, 2015 at 01:45 pm Comment: Arrive 15 min before appointment time. Bring picture ID and insurance card. nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 4

5 Mrs. B Narrative Note: main complaint is redness to R eye, noted by her daughter. no vision changes. no eye pain. no HA. exam with small subconjunctival hemorrhage however, pt with other complaint of tremor to L arm x 1 month. pt with no PCP, has not seen a doctor in several years (>30). Patient lives with daughter Amber, her other daughter just moved away to Aurora, (suburb in Chicago) and her daughter don't get along. Patient states she only gets Soc. Sec and barely makes it. Patient has not seen a MD for 33yrs. " I don't like coming to hospitals." Poor hygiene but able to walk independently bend down, go on stairs. Patient cognitively intact. Very nervous to be here. Plan: Jamila saw Jane and will follow up for PCP and Neuro follow up appt. If d/c home. Louise ( MD note) Nov. 26, year old female with pmh of morbid obesity, psoriasis? Brain tumor s/p shunt, presents w/ worsening hip pain and urinary incontinence w/ increased frequency. Patient unable to ambulate 2/2 left hip pain, has been home-bound x 1.5 years. Can not ambulate or cook for self, just moves around on a rolly-chair at her apt. Louise s (GEDI Note) Patient called EMS to bring her to ED for evaluation 2/2 urinary frequency. Report lives alone on 2nd floor of building in condo. Has stairs in building but no elevator. Patient has not left building in >1year due to the inability to walk. Patient unable to ambulate due to hip and lower leg pain. Uses 3 desk chairs w/wheels to get around condo. Has had several falls and has had to call 911 to get up off of floor. States last 3 months has had frequent urination and stopped taking sleeping pill for fear of urinating in bed. For the past 1 month has been unable to get into bathtub to bathe due to lower leg pain. Reports is independent in bathing (taking a sponge bath at sink), dressing, and moving around condo on rolling chair. Organizes own medications. Calls grocery store for delivery and then heats up frozen dinners in microwave. Hires friend as housekeeper 1x per week. Patient has no family and relies on friends for help. Discussed need for placement into SNF but patient states, "I want to live in my own home. I like my home, I'm not ready for that". If patient were to go home today will write RX for RN home health assessment and eval / P.T. eval. SW consult for DOA homemaker/meals on wheels/and HPOA. Discussed situation w/ Dr. Matthews and Dr. Byrne and pt. most likely to be admitted if not for medical reason for socialsafety issues. P.T. order placed to see patient on floor. nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 5

6 Louise s Call backs Patient discharged on Nov. 28th Dec (24-72) Call back Dec ( Follow up call and day) Dec 1829 ( Social worker Bailey) Dec 1517 ( day) Dec 1715 Dec 1800 ( Finally wheel chair delivered ) Conclusion I strongly believe that hours are essential when discharged from the ED day call back is more essential when patients are discharged from the hospital and to ensure that they returned home safely. nicheprogram.org 2015 Annual NICHE Conference Innovation Through Leadership 6