Question

Ms.B is a 85 ylo Italian who immigrated to America 50years ago with a 6 grade education from Italy. She was admitted to the hospital with exacerbation of CHF. Her co-morbidities are diabetes and osteoporosis. While in the hospital her daughter- primary care giver suffers a MI and is now recuperating at home. Ms. B lives with her daughter Barbara and son-in-law, John. Barbara is requesting you the Case Manager to arrange for her mother to be sent to a rehab center. The request is so Barbara may recuperate from the MI and not place a double burden on her husband. You call a team meeting and announce the request. You inform the team that Ms. B has traditional Medicare, is eligible for Medicaid. The family has not completed a Medicaid application because they were unaware of Ms. B's eligibility. You also inform the team that there are no Health Care Proxies signed. O Can you grant the family's request? O Identify 2 reasons why the Health care Proxy should be completed 3 What benefit will completing the Medicaid application now have for the transition of Ms. B back to the community? Based on the Transitional Care Model formulate the full plan of transition Based on Purnell identify 3 cultural issues which may occur during the transition period (O Develop an education plan for the patient and family to prevent re-hospitalization related to CHF

Answer 1

ANSWER (1).Health care proxy form is an important legal document. Health care proxy law allow one to appoint someone whom he or she trusts. This document assign the power to one choosen person to take all the health care decision for the patient including removal or continuation of life support of the patient on on behalf of the patient.

Until and Unless the form is signed , as in this case the family's request can not be granted.

Ans (2) Health care proxy form to be completed bacause

i.It is a legal documentation of the patients wishes .Without this document the health care agent become legally liable for any decision taken .because then no proof is there that patient appoints you to take any decision on his or her behalf.

ii.Payment/Income received for being an agent will not be supported by any document

Ans( 3) Medicaid coverage will be an added advantage. It is a medical insurance programme which provide free or low cost health coverage to some low income people.So it can cover her rehab centre cost including treatment

Ans (4) Full Plan of Transitional Care support

Suitably planned hospital based TCP provides smooth transition from inpatient to outpatient setting preventing readmission.

The specific intervention includes

Predischarge

Post discharge and bridging strategy

Includes a hospital based discharge planning and home follow up.

Medication management

Maintenance of patients health Records

Close follow up with a primary provider

Identification of warning sign and indications that will ask to contact patient's health provider

An advance practice nurse will visit the home and communicate with the patient,if needed telephonic follow up too.

These strategies will reduce readmission rate .