Complex Case Complex Case ManagementManagement

Complex ManagementComplex Management

Heart FailureHeart Failure

Chronic Obstructive Pulmonary DiseaseChronic Obstructive Pulmonary Disease

Frail ElderlyFrail Elderly

Heart FailureHeart Failure

Heart failure (CHF) is a condition in which Heart failure (CHF) is a condition in which the heart's function as a pump is the heart's function as a pump is inadequate to deliver oxygen rich blood to inadequate to deliver oxygen rich blood to the body. the body.

Impact of Heart FailureImpact of Heart Failure

5.8 million people in US Dx of HF5.8 million people in US Dx of HF 670,000 new cases will be Dx 2010670,000 new cases will be Dx 2010 34 billion spent per year34 billion spent per year 1 million hospitalizations1 million hospitalizations Leading case of hospitalizations 65>Leading case of hospitalizations 65> 33% pts. are readmitted in 3 months33% pts. are readmitted in 3 months

emedicine

Causes of Heart FailureCauses of Heart Failure

CADCAD HTNHTN DiabetesDiabetes Valvular Heart DiseaseValvular Heart Disease CardiomyopathyCardiomyopathy Drug & Alcohol AbuseDrug & Alcohol Abuse

Treatment of Heart FailureTreatment of Heart Failure

Diuretics= Lasix,Bumex & ZaroxolynDiuretics= Lasix,Bumex & Zaroxolyn Ace Inhibitor= Lisinpril,Altace&ZestrilAce Inhibitor= Lisinpril,Altace&Zestril ARB’S= Micardis,Diovan & CozaarARB’S= Micardis,Diovan & Cozaar Life Style ChangesLife Style Changes Fluid RestrictionFluid Restriction

Case StudyCase Study

75 year old women75 year old women Hs. CAD and HTNHs. CAD and HTN Medications: Toprol XL 100MG QD,ASA Medications: Toprol XL 100MG QD,ASA

81MG QD,Zocor 80mg HS,Lasix 20mg qd81MG QD,Zocor 80mg HS,Lasix 20mg qd S/P Hospitalization for PneumoniaS/P Hospitalization for Pneumonia 7 day LOS 7 day LOS Discharged to home aloneDischarged to home alone

Post Discharge CallPost Discharge Call

CM/CC calls pts. 48hrs after dischargeCM/CC calls pts. 48hrs after discharge Medication reviewMedication review Do you have any swelling ? If yes is it gone Do you have any swelling ? If yes is it gone

when you wake in the morning ?when you wake in the morning ? How did you sleep last night ?How did you sleep last night ? How is your breathing?How is your breathing? Are you able to the things you did prior to being Are you able to the things you did prior to being

in the hospital ?in the hospital ? Do you have a cough ? Is yes is it productive?Do you have a cough ? Is yes is it productive?

Office Heart Failure ReferralOffice Heart Failure Referral

PCP referral for HFPCP referral for HF 70 year old with newly diagnostic HF70 year old with newly diagnostic HF History of MI,CAD,HTN &DMHistory of MI,CAD,HTN &DM Presented to office 1 week ago with lower Presented to office 1 week ago with lower

leg swelling , SOB, inability to lay downleg swelling , SOB, inability to lay down PCP treated with Lasix 40mg qd and PCP treated with Lasix 40mg qd and

ordered an ECHO which reveled an EF of ordered an ECHO which reveled an EF of 20%.20%.

HF ManagementHF Management

What education or instructions should be What education or instructions should be given to the pt. ???????????given to the pt. ???????????

DTP Smart Set ToolDTP Smart Set Tool

04/20/23 12

Diuretic Titration Protocol

COPDCOPD

Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by (COPD) is a lung disease characterized by chronic obstruction of lung airflow that chronic obstruction of lung airflow that interferes with normal breathing and is not interferes with normal breathing and is not fully reversible. Commonly known as fully reversible. Commonly known as emphysema and bronchitis.emphysema and bronchitis.

Impact of COPD Impact of COPD

24 million people 24 million people 50% are not aware they have COPD50% are not aware they have COPD 44THTH leading cause of death in the US leading cause of death in the US One of the leading causes of disability in One of the leading causes of disability in

the USthe US

National Heart Lung and Blood Institute.com

Causes of COPDCauses of COPD

SmokingSmoking

Environmental FactorsEnvironmental Factors

Genetic Factors (AAT deficiency)Genetic Factors (AAT deficiency)

Frequent respitory infections in childhoodFrequent respitory infections in childhood

Treatment of COPDTreatment of COPD

Inhalers = Atrovent,Albuteral&CombiventInhalers = Atrovent,Albuteral&Combivent Nebulizers= Nebulizers= DuoNebDuoNeb Steroids=Oral&InhaledSteroids=Oral&Inhaled OxygenOxygen Remove environment factorsRemove environment factors Stop smoking Stop smoking

Case StudyCase Study

58 year old male58 year old male Presents to PCP office C/O SOB with Presents to PCP office C/O SOB with

activity, productive cough for yellow activity, productive cough for yellow secretions . C/O difficulty with secretionssecretions . C/O difficulty with secretions

History of smoking 2 ppd for 38 yearsHistory of smoking 2 ppd for 38 years Frequent respiratory infections over the Frequent respiratory infections over the

past yearpast year

Case Study COPDCase Study COPD

Pulse OX is 90 during ambulation Pulse OX is 90 during ambulation requiring periods of restrequiring periods of rest

Treatment: Z-Pack and tapering dose of Treatment: Z-Pack and tapering dose of PrednisonePrednisone

Nebulizer qid with Duo NebNebulizer qid with Duo Neb CC/CM meets with pt. what should the CC/CM meets with pt. what should the

education be focused on ?education be focused on ? What’s the follow-up plan for this pt ?What’s the follow-up plan for this pt ?

Frail ElderlyFrail Elderly

Older persons (usually over the age of 75 Older persons (usually over the age of 75 years) who are afflicted with physical or years) who are afflicted with physical or mental disabilities that may interfere with mental disabilities that may interfere with the ability to independently perform the ability to independently perform activities of daily living.activities of daily living.

Impact of Hip FractureImpact of Hip Fracture

350,000 Fx per year350,000 Fx per year

25% will return to their pre injury level of 25% will return to their pre injury level of functionfunction

25% mortality rate in the 1rst year25% mortality rate in the 1rst year

Case StudyCase Study

Mrs. Jones daughter calls stating that her Mrs. Jones daughter calls stating that her Mom has been falling at home, not eating Mom has been falling at home, not eating and at times forgetful. Mrs. Jones lives and at times forgetful. Mrs. Jones lives alone in a 2 story home and drives.alone in a 2 story home and drives.

Appt. is made with PCPAppt. is made with PCP PCP evaluates pts and orders testingPCP evaluates pts and orders testing CC/CM meets with the pt. and her CC/CM meets with the pt. and her

daughter at PCP appt. daughter at PCP appt. What’s next ??What’s next ??