CLINICAL PEARLS FOR SUCCESS IN MEDICAL RESPITE 2018 MEDICAL RESPITE TRAINING SYMPOSIUM PHOENIX, ARIZONA OCTOBER 1-2, 2018
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1 CLINICAL PEARLS FOR SUCCESS IN MEDICAL RESPITE 2018 MEDICAL RESPITE TRAINING SYMPOSIUM PHOENIX, ARIZONA OCTOBER 1-2, 2018 PRESENTERS: DAVE MUNSON, MD MEDICAL DIRECTOR BOSTON HEALTHCARE FOR THE HOMELESS KIM DESPRES, RN DHA RN PROGRAM DIRECTOR CIRCLE THE CITY
2 LEARNING OBJECTIVES Understand the variety of staffing models used in medical respite Review admission criteria for medical respite programs Discuss specific clinical scenarios and review best practices for successful and safe care
3 TYPES OF MEDICAL RESPITE Apartment/Motel rooms Homeless Shelter Transitional Housing Assisted Living/Nursing Home Substance Abuse treatment Stand-alone facility
4 STAFFING MODEL EXAMPLES Substance abuse clinic On site clinic Nursing home/assisted living Contracted services Potential to utilize existing staff Shelter based and transitional housing Contracted services Home care Providers
5 STAND-ALONE RESPITE STAFFING MODEL Providers 7 days a week Two providers per day for 50 patients MD on call nights and weekends Nurses 24/7 Three nurses (2 LPN s and 1 RN) daily One LPN at night Behavioral Health Psychiatry: both contracted and employed Substance abuse mental health counseling
6 STAND-ALONE RESPITE STAFFING MODEL Security Health unit coordinators Case management Two for 50 patients Physical therapy Driver Respite assistants Two on day and one on nights
7 STAND-ALONE RESPITE STAFFING MODEL Volunteers, Volunteers, Volunteers!!
8 Edgar
9
10 In memory..barney
11 MEDICAL RESPITE: ADMISSION CRITERIA I KNOW IT WHEN I SEE IT
12 MEDICAL RESPITE: ADMISSION Clinical Considerations CRITERIA Behavioral Considerations Staffing/facility considerations Partnership considerations
13 ADMISSION CRITERIA: CLINICAL CONSIDERATIONS Case: 55F with T2DM, CKD, opioid use disorder (OUD) referred to medical respite from hospital after right below knee amputation. Relevant issues in referral: Newly on insulin and prescribed QID finger sticks/injections On short acting pain medication but would like to start treatment for her opioid use disorder Daily wound care dressings at surgical site Discharge summary requests weekly labs Worked with physical therapy in hospital and struggled with transfers. Skilled rehab was recommended but the patient could not be placed.
14 ADMISSION CRITERIA: CLINICAL CONSIDERATIONS Independence with ADLs Substance Use Disorders Ability to do detoxification Ability to initiate buprenorphine (x-waiver required) Medication independence/safety
15 ADMISSION CRITERIA: CLINICAL Laboratory monitoring CONSIDERATIONS Primary psychiatric patients Medication independence/safety
16 ADMISSION CRITERIA: BEHAVIORAL CONSIDERATIONS Case: 34M with TBI, alcohol use disorder (AUD) and recurrent cellulitis of his toe referred to medical respite by street medicine team: Refuses to go to ER/hospital but seems appropriate medically for respite and he wants to come in There is a potential housing opportunity for him He is prone to outbursts and during his last time in respite (18 months ago) he was verbally abusive to staff resulting in a bar
17 ADMISSION CRITERIA: BEHAVIORAL CONSIDERATIONS Issue #1: Safety How to ensure that staff feel safe. How to ensure that other patients feel safe Issue #2: Bars/Readmission Criteria How long of a bar is long enough What is the process for mitigation Issue #3: Support Develop behavioral support plans
18 ADMISSION CRITERIA: FACILITY CONSIDERATIONS Quick Case 1: 56M with COPD on 2L O2 is referred from hospital after a COPD exacerbation How will you ensure he has enough oxygen? Quick Case 2: 64F with morbid obesity is referred for management of RLE cellulitis Do you have adequate facilities (bed, toilet) to support the patient? Quick Case 3: 34M with TBI, PTSD admitted for diabetes management. He has an emotional support dog. Can you accommodate the patient and his animal
19 ADMISSION CRITERIA: PARTNERSHIPS Tailor your services to the needs of your partners
20 ADMISSION CRITERIA: IMPLEMENTATION Standardized referral process Dedicated staff Eyes on the ground
21 ADMISSION CRITERIA: EYES ON THE GROUND Dedicated Nurse - Liaison Two days a week at major referring hospital Rounds on homeless inpatients Coordinates with inpatient teams, ER Close contact with our admissions office
22 3 CASES TO DISCUSS AND DEVELOP Break into 3 groups For your assigned case 1) Discuss any barriers 2) Explain any policies or procedures that would need to be developed 3) Discuss any trainings that staff would need
23 CLINICAL SCENARIOS AND BEST Opioid use disorder PRACTICES 52M with AIDS and OUD is referred from hospital for wound care related to an abscess. He has pain related to his dressing change and remains on oxycodone 10mg BID but wants to start MAT during his respite stay. What processes do you need to be able to accept this patient What staff trainings and skills are required Develop a protocol that would allow your program to care for this patient
24 CLINICAL SCENARIOS AND BEST Bed bug infestation PRACTICES Cleaning staff or nursing assistants started the weekly cleaning of the female dorm While changing the sheets, they noticed black dots on the box spring cover. They weren t quite sure what to do What does your staff do at this point Who do they report this to? What are next steps? What is your policy and procedure for detecting and preventing bed bugs? Were all steps followed? Lessons learned?
25 CLINICAL SCENARIOS AND BEST IV antibiotics PRACTICES 28F with OUD is referred from hospital to complete a 6 week course of IV vancomycin for septic arthritis. What processes do you need to be able to accept this patient What staff trainings and skills are required to care for her safely How would you manage her OUD? Develop a protocol that would allow your program to care for this patient
26 BEST PRACTICES OPIOID USE DISORDER Recognize and treat withdrawal COWS assessment built into EMR Detox/induction protocol with buprenorphine Increase behavioral health support Daily SUD group, individual counseling as needed Support staff!! Trauma informed care trainings Small group sessions to address behaviors/burn out
27 BEST PRACTICES - INFESTATION
28 BEST PRACTICES: IV ANTIBIOTICS Admission criteria Require central access (PICC vs midline) before admission Require confirmation Pharmacy Clinical guidelines Frequency of dosing Administration of medication Teaching and training
29
30 Questions/ Discussion
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