According to the CDC, millions of people 65 and older fall yearly at an estimated cost of $31 billion in medical expenses alone per year. As an RN Care Manager, two key goals are to keep the patient at home and to prevent hospitalization.
Overview of patient
72 yo male with dx of Diabetes, Arthritis, Hypertension, Chronic Kidney Disease, Depression and Vitamin D deficiency.
Signallamp Health’s Approach
Due to the patient’s wide-ranging and multiple chronic conditions, the physician believed monthly monitoring would be beneficial and enrolled this patient into the Chronic Care Management Program.
Lisa, a registered nurse at Signallamp Health, reached out to her patient Martin for her monthly call. Lisa opened the call with “Have you had any changes since the last time we spoke, Martin? Martin replied with “Well, I feel my arthritis has been acting up since it has been so cold out, and I am starting to feel unsteady on my feet. I am also worried about falling.?
Lisa knows that due to patient’s PMH and his comments patient is (or may soon be) at risk for falls. However, Lisa would like to validate this fall risk with a self-assessment tool.
“Martin, have you fallen in the last year? Lisa said. Martin replied, “I fell about 6 months ago, leaving a restaurant.? Lisa then assesses Martin’s use of an assistive device, and she finds out that he doesn’t use it because he isn’t sure if he is using it properly. She also learns that he must push up with his hands to stand from a sitting position and reports that, “I have to hold the furniture for balance while I walk around the house.? Based on this brief but personal interaction, it is clear to Lisa that the patient is at significant risk for falls.
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In the course of her EMR chart review, Lisa can also see that patient has not had a referral for Outpatient Physical Therapy. Lisa reports her findings to the physician with a recommendation for Outpatient Physical Therapy.
Physician replies to Lisa to report that Outpatient Physical Therapy was ordered for Martin and that he would like Lisa to call patient bimonthly during his treatments.
Results
Patient went to Outpatient Physical Therapy 3 times a week for 4 weeks. Patient learned how to use a cane and is confident in using it. Lisa continues her monthly calls to patient.
