Snohomish County Case Management Nursing Services Carolyn Hundley, RN /Supervisor Denice Ulowetz, RN Kirstie Clinko, RN Sue Lee, RN Joy Maine, RN Amy Robertson, RN
Overview New Changes in Nursing Services Nursing Referrals RN On Call Transitional Care
Nursing Referrals Two Ways to Make Nursing Referral 1. Nursing Referral Forms (2) Skin Observation Protocol RN Services Referrals (Non-SOP Referrals) 2. Nursing Referral Phone Line
Nursing Referral Phone Line Who would call? - Case Managers in the field When to call? - Skin Observation Protocol Client meets highest risk indicators and a non-professional is providing care to a skin problem over a pressure point. Need the same day referral as the assessment CMs can leave messages on Nursing Referral Line Document that the referral was made at the time of assessment Fill out the SOP referral form upon return to office - Any nursing related burning questions in the field
RN On-Call 1. Check Nursing Referral Line At least twice a day (AM/PM) Answer CMs questions in the field 2. Check Nursing Referral Drawer Assign Referrals to RNs SOP & RN Services Referral Forms
RN On Call Calendar
Transitional Care How Nurses get involved in Transfer-in Cases
GOAL To Assess the Cause and Prevent Readmission to Hospital or Institutional Settings
Procedure RN Supervisor Reviews - All Transfer-in Cases In CARE Case Aid Manager Reviews - Individual Providers Contract, FBI Fingerprint, BG Check Training Records, Certifications Lead CM Reviews - Financial, Coding on CARE, TCM, Caregiver Status, Documents on DMS, Equipment Identify Clients at Risk CTR Sheet RN Supervisor CM Supervisors Assign to RNs Assign to CMs
CTR Sheet by Case Aid Manager Review by CM Lead Brief Note by RN supervisor
Procedure RN Supervisor Reviews - All Transfer-in Cases In CARE Case Aid Manager Reviews - Individual Providers Contract, FBI Fingerprint, BG Check Training Records, Certifications Identify Clients at Risk CTR Sheet Lead CM Reviews - Financial, Coding on CARE, TCM, Caregiver Status, Documents on DMS, Equipment RN Supervisor CM Supervisors Assign to RNs Assign to CMs
All Transfer-in Cases reviewed by RN Supervisor
Criteria for Transitional Care Things We Look For Clients discharged from Hospital / SNF, AFH Home Clients with Frequent Hospitalizations Any concerns found during CARE & SER Review
REVIEW - Most Recent CARE Assessment - Initial CARE Assessment - SERs
REVIEW - Reason for Assessment - History Returning Client?
Procedure RN Supervisor Reviews - All Transfer-in Cases on CARE Case Aid Manager Reviews - Individual Providers Contract, FBI Fingerprint, BG Check Training Records, Certifications Identify Clients at Risk CTR Sheet Lead CM Reviews - Financial, Coding on CARE, TCM, Caregiver Status, Documents on DMS, Equipment RN Supervisor CM Supervisors Assign to RNs Assign to CMs
RN File Review Things We Evaluate Involves Presenting Health Problem Diagnoses / Disease Management Medication Management Pain Management Skin Issue Mobility Issue Hx of Fall Equipment Needs Unmet Needs Historical Date Hx of non-compliance Any Cognition / Mental Health issue that might affect their ability to manage their health at home Health Care Coordination
After File Review Schedule RN Home Visit (in 1-2 weeks) RN HV Independently or Joint HV with CM as Needed Follow UP As Needed RNs May Do 30-day HV / Sig. Change As Needed
Case Scenarios Presented By - Denice Ulowetz, RN - Kirstie Clinko, RN
Rn Case Review Jane John Joan Jennifer JoAnne Jerry
Jane 73 yr old Lady with Epilepsy, oppositional behaviors, Dementia symptoms Transferred from Skagit county where she was living alone and exhibiting unsafe behaviors including accidentally setting fire to her apartment. Currnetly Living alone in senior apartment building Refusing care Firing Agency Caregivers Refusing Medication Wandering
John 65 yr old male client. Elite fitness the core of his identity and then one early December morning client needed cream for his coffee and was walking his bike across the road when a truck hit him at 50 miles per hour Underwent multiple surgeries and was at Harborview in a coma for several months. He recovered enough to attempt rehab and was transferred to Rehab facility. Home with untreated pain preventing client from participating in PT
Joan 73 year old lady with CHF, IDDM, COPD, Osteoarthritis, hx of flap surgery for R hip pressure ulcer, Significant Cognitive Deficit. Was in AFH and recently discharged to Daughter s home. Daughter has a toddler and works full time out of home. Major problems were rectal prolapse, pressure Ulcers, and chronic pain treated with narcotic pain medication, which would run out in two days. Needed Labs drawn post G.I. visit. No lab visit set up. When left AFH clt could no longer see the MD who was seeing her there and her A.P. had assisted clt to identify a new primary MD, whom client had not yet seen but she did have an appointment two weeks hence.
Jennifer 39 yr old client with M.S., Morbid Obesity, Significant Lymphedema both lower legs. Client was hospitalized with pneumonia and post fall during transfer with shoulder injury. To f/u with wound center for Lymphedema tx but had not made appointment by day of HV.
JoAnne 72 yr old lady CVA and Rehab stay from which client left AMA
Jerry 54 yr old male clt with IDDM, Cognitive impairment, Neuropathy, Hypertension, COPD Recently hospitalized for Diabetic Ulcer resulting in amputation of R toe CG Agency reported client s blood glucose readings had been in the 500 s for the last two weeks Clt Blood pressure and on day of home visit BP was 163/109 Clt reported he was prescribed Lisinopril but it caused Hypotensive crisis and was stopped
Lorraine 51 yr old female discharged to home after 3 month rehab stay at SNF for multiple fractures sustained from MVA. Developed osteomyelitis infection which was treated with IVAB prior to DC. Lives with spouse who is unable to provide informal support. REASON FOR RN INVOLVEMENT: SNF discharge to home DIAGNOSES: Type 2 diabetes CAD Obesity Depression and bipolar disorder
Lyubov 85 year old female with hx frequent emergency department visits due to medication mismanagement. She d had at least 2 falls; one resulting in wrist fx. Lives with her daughter/ip in 2- level home. REASON FOR RN INVOLVEMENT: Frequent ED visits R/T med mismanagement DIAGNOSES: CHF Atrial fibrillation has pacemaker HTN Asthma Type 2 diabetes with neuropathy Osteoporosis Colon cancer receiving oral chemotherapy
Lars 82 year old male with progressive supranuclear palsy who lives with his spouse and daughter/caregiver. Home health hospice services in place. REASON FOR RN INVOLVEMENT: Weight loss and near falls DIAGNOSES: Hx heart attack Hx stroke Aphasia
Lucille 73 year old female discharged to SNF following hip surgery. AFH placement was recommended but declined by clt. Lives alone in single level apartment. REASON FOR RN INVOLVEMENT: Ensure safe home plan for clt who declined residential placement DIAGNOSES: O2 dependent COPD Hx stroke Dementia
Leticia 77 year old female with multiple hospitalizations/snf placements R/T falls or CHF/COPD exacerbations with hx leaving AMA. AAA CM was contacted by local FD for frequent 911 calls 21x in last year. FD reports clt removes her O2 which causes confusion and makes her combative; falls occur when she slips from her recliner. Some calls included non-emergent issues recliner not working properly. REASON FOR RN INVOLVEMENT: Frequent falls, high 911 use and hx leaving AMA DIAGNOSES: O2 dependent COPD CHF Hx stroke Bipolar and anxiety disorder
Questions?
Contacts Carolyn Hundley, RN / CM Supervisor (425) 388 7242 Carolyn.Hundley@snoco.org Snohomish County Case Management (425) 388 7296
THANK YOU!