Family Discharge Case Study

The hospital that I worked for while working as a case manager was not in network with Kaiser Permanente. It was also the time when the hospital started to hire hospitalists to manage patient care while they are a patient in the hospital. It actually worked out because it filled in the gap in patient care. The hospitalists were acting as the patient's primary care provider. Kaiser as with many other insurance have a case manager designated to ensure that the patient is meeting criteria not only for an inpatient hospital stay but for the level of care they are receiving as well such as ICU, Stepdown, or Med-Surg. I would have to give them an updated clinical information daily or every 3 days depending on the severity of illness. As a case manager, I was responsible for discharge planning and I preferred to transfer the patients to

OFC Montejano made contact with the Hegle at Primary Care Desk B lobby. Where the she gave an omission and stated she had an appointment and because the Johnson was not at her desk she missed it. Further, she claims Dr. Little told her she could get the Tens Unit right away. I did however confirm that Hegle did not have and appointment for the use of the Tens Unit. Hegle was given a verbal warning that this type of behavior will not be tolerated and she could be charged with Disorderly Conduct in the future. Hegle departed VA Controlled property without further

On Tuesday July 7, 2015, at approximately 3:01 PM, Kiana Beekman, (MFCU Investigator) (Beekman) received a call on the state office telephone from HILL, Lucy (Service Facilitator of Lucy Hill Services (LHS). During the conversation, Beekman asked HILL to clarify her role and responsibilities as a service facilitator, in addition to the role and responsibilities of HARRIS, LaFrance as the Employer of Records (EOR) for Medicaid Recipient DANIEL, Rose and MCGHEE, Inocencia as DANIEL’s aide. She was also asked to provide any documentation of training on timesheet submission and approvals that she provided HARRIS and MCGHEE under the Department of Medicaid Services (DMAS) Consumer-Directed care aide program.

Counselor red flagged pt. and requested that he meet for brief TX intervention to discuss his current counseling non-compliance status and explaining the risk of discharge from the program if he fails to do an individual session by 1/22/17. AMS receptionist told this writer that pt. is asking why he needs to meet with this writer. This writer told him to inform him that if he fails to complete one hour individual session by 1/22/17 he will be subject for a TX discharge. Pt. refused to meet with this writer and he failed to schedule an individual session on the above date.

On 9/15/2016, CM met with the client for Bi-Weekly ILP Review. Client was dressed appropriately for the weather. She was well groomed. As usual client in the meeting was loquacious, and loud. Client continues to be hostile towards this worker. Client continues to repeat to this worker as quote: "I am not mad with you, and this has nothing to do with you. It's all about DHS and your supervisor." Client was hostile due to an Authorization of Release Form client signed for staff to contact her therapist Dr. Iris Yankelevich for a copy of the client psychosocial and psychiatrist evaluations. Client continues to report that she didn’t signed the Authorization of Release Form because the form stated that the form is for HRA 2010e and she doesn’t know how many time she need to repeat herself that she doesn’t meet the ‘CRITERAI FOR SRO”. CM tries to explain to the client that staff is requesting a copy of her psychosocial and psychiatrist evaluation, but then client continue to talk over CM and threat to contact the Coalition and DHS. Client continues to set in her way and refuses to work with staff to meet her unmet needs. CM observed that the client walk with a book bags and a small shopping cart. Client reported she walk with all her documents and letters from Adult Protective Services & Social Security Administration stating that she is capable of living independently.

This officer has had contact via face to face and phone with the mother, Ms. Evelyn Edwards. Discussions have taken place with her regarding Marquel’s Comprehensive Re-Entry Case Plan. She has participated in a video conference with Marquel since his commitment. She is aware of his placement in the Virginia Beach CPP Program. She has not visited him at the facility, but she has had contact with him via phone. She is currently unemployed. Upon Marquel’s release from DJJ, the anticipated parole plan (CRCP) will be for him to return to her home with intensive supportive services via 294 funding. Additionally, in the event this placement is no longer available, an alternative placement will be sought via 294 funding for a group home placement or

This case involved Donna Grady being a danger to herself. Grady was transported to Exodus Urgent Care, where she was placed on a WIC 5150 hold.

Ana Liu-Dilarno, Chief Nursing Officer: Ms. Liu-Dilarno had no involvement in the mentioned incident however wishes to be a part of the process in creating procedures in order to avoid any further situations involving her nursing staff.

At approximately 11:36 hours, the writer and S/O C.Mason responded to a call from POC to attend MHSU for an eviction. The officers attended and met with the clinical staff (Tav Randhawa), who informed the officers that the discharge patient in consult room #9, need to be escorted off property. The officers were also told that the patient is really agitated and might put into a fight. The writer requested for two additional officers to attend and assist them with the call. S/O C.Mason broke up from the call and returned to the main booth to relieve SSS J.McCuaig, so he can attend.

SC end call with Pa and placed call to PowerBack Rehab and spoke with Gwen a receptionist. SC identified-self, where SC is calling from and stated reasons for calling. SC requested to know the Pa’s admission and discharged dates to PowerBack rehab. Gwen reported that the Pa was admitted to the facility on 12/22/2015 and discharge home on 1/22/2016. SC asked the reason for Pa’s stay and Gwen stated she was unable to access that information and forward SC to the social service department where SC got Stephanie Black VM. SC left a detailed message with contact information and ended call. SC placed called to Hahnemann Hospital admission department and spoke with Yolanda. SC Identified self and sated reason for calling. Yolanda verified Pa’s stated claims of the date she was admitted and discharged. The Pa was admitted to the hospital on 12/14/2015 for surgery and discharged to PowerBack rehab on 12/22/2015. SC thanks Yolanda and ended call. SC then placed call to PPL and was on hold for some time but later spoke with Quincy. SC identified self and stated reason for calling. The SC asked Quincy if the DCW was paid for any day(s) from

Mr. Flowers is a 41 year old male who presented to the ED via LEO under IVC from Daymark Recovery Services. TACT assisted ED staff with deescalating Mr. Flowers after being informed of Mr. Flowers was becoming agitated. Mr. Flowers was concern about when he was able to leave and was under the impression he could leave tonight. TACT spoke with Paige from MCBH who informed TACT that MCBH was still seeking placement for Mr. Flowers. Mr. Flowers was informed of the current status of his disposition. Mr. Flowers gave this clinician verbal permission to speak with his wife Vickie Flowers about the status of his disposition and explain the process to her. This clinician explain the process and informed her of status.

Writer received a call from Marvin concerning her SPOA application. Care manager used that opportunity to formally introduce myself, and also asked when he applied. Marvin had no knowledge of it but he shared his counselor's number with me to call her for details about the application.

The rehabilitation management of a stroke patient with multiple impairments as illustrated in this case report warrants early rehabilitation referral and requires an effective interdisciplinary teamwork to ensure prevention of further complications as well as to improve the patient’s function and independence. This patient who had undergone left transtibial amputation and had a chronic right forefoot diabetic foot ulcer unfortunately suffered a stroke resulting in left hemiparesis, leaving the managing team in a difficult situation to balance between patient’s independence in function with safety.

Case Study: An Intervention to Improve the Hospital Discharge Process Introduction The hospital often discharges patients with insufficient planning, poor instruction, inadequate information, and lack of coordination among members of the health-care team. Inefficient discharge process is one of the key contributors to 30 days readmission. According to appendix A, the hospital re-admission rate for Medicare patients was between 19 % and 17.7% from 2007 to 2013. The cost of unplanned readmissions is 15 to 20 billion dollars annually (Alper, O’Malley, Greenwald, 2017).1 Thus, minimizing post-discharge readmission has become a priority for the US health care system.

SSA met with Rachel Perlstein-Behavior Support, Keyanta Shauntee and Robert with Beyond All Limitations. We discussed that Beyond All Limitations has a few concerns with team communication and would like clarification on few incidents in which the agency was made aware of after the event occurred. First she spoke about the housemate situation which was discussed at the previous Resilience Meeting. She shared that staff Robert came back and reported that CCBDD had found a housemate option for Curtis to pursue when BALL was not aware that one was being pursued on his behalf. We discussed that this was an action item from previous Resilience Team meetings where Curtis continually requests a new housemate. CCBDD followed up per the action item.