Panel: Preventing Readmissions in those with

Memory Impairment

Kim Butrum MS, RN, GNP: ModeratorJim McAleer MPALeslie Zun MD

Nicholas Jauregui MD

October 16, 2014

The Evidence

• Memory impairing diseases are a significant area of concern in reducing readmission rates.

NRPC So Cal Readmissions UpdateOctober 16, 2014

Utilizing Clinical Outcomes to Prevent Readmission in those

with Dementia

Kim Butrum MS, RN, GNPVice President- Health Service

Silverado

October 16, 2014

Use of Clinical Outcomes:The Silverado Experience

• Through the collection of clinical outcomes over the past 18 years, Silverado has reduced both their 30 day readmission rate and transfer to the acute rate to industry leading levels.

:NRPC So Cal Readmissions UpdateOctober 16, 2014

How do we do it?

• Our culture • Education and training • Early identification and management of a

behavioral or functional change• Alignment with strong partners for both

extra support and palliative care/hospice care at different points of the disease

NRPC So Cal Readmissions UpdateOctober 16, 2014

Don’t Prevent Readmission – Promote Community

Retention…

Presented by Jim McAleer., MPAPresident/CEO

Alzheimer’s Association

October 16, 2014

Objectives • Know what community programs and

services can make a difference

• The Caregiver matters

• Preventing readmission begins long before the patient leaves the hospital

• Alzheimer’s Association Case Study

NRPC So Cal Readmissions UpdateOctober 16, 2014

Dealing with Patients who have Memory Impairment in the Emergency Department

Leslie S Zun, MD, MBA, FAAEMChairman and Professor

Department of Emergency MedicineRFUMS/Chicago Medical School

Mount Sinai HospitalChicago, Illinois

October 16, 2014

Objectives

• Understand the role of the emergency department in evaluating memory impaired patients

• To determine if the patient has a medical, psychiatric, substance use or behavioral problem

Case #1

• 64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history.

• What further information is needed?

• What to look for in the physical exam?

• What testing is indicated?

Medical ClearancePurpose

• Primary Purpose - To determine whether a medical illness is causing or exacerbating the psychiatric condition.

• Secondary Purpose - To identify medical or surgical conditions incidental to the psychiatric problem that may need treatment.

Primary Purpose Etiology

• Drug and alcohol intoxication or withdrawal

• Medical • Hypoglycemia• Hyperthyroidism• Delirium• Dementia• Head Trauma• Temporal Lobe

Epilepsy

• Psychiatric

Psychiatric

Medical

DeliriumDementia

Hyperthyroidism Head Trauma

Temporal Lobe Epilepsy

SchizophreniaBipolsr IllnessDepression

Drug intoxication/withdrawal

Delirium vs. dementiaDelirium Dementia

Onset Acute Slow

Awareness Reduced Clear

Alertness Fluctuates Normal

Orientation Impaired Impaired

Memory Impaired Impaired

Perception Hallucinations Intact

Thinking Disorganized Vague

Language Slow Word finding difficulty

Primary Purpose - Differentiate Medical from

Psychiatric Etiology• Age >45 years old

• Prior psychiatric/medical history

• Abnormal vital signs

• Physical examination findings

• Cognitive deficits

• Focal neurologic findings

• New or different psychiatric complaints

• Laboratories?

• Advanced testing?

Case #1 64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history.

• What information is needed?• Prior psychiatric history - none• History of medical problems – DM, HTN, CVAs• Use of drugs and alcohol - Denies

• What to look for in the physical exam?• Vital signs – tachycardia & hypertensive• Focal deficits – right sided weakness• Signs of intoxication – Heightened consciousness

• What testing is indicated?• CBC, electrolytes, UDS, alcohol level• EKG, CT scan head, CXR

• Diagnosis – Delirium from Hyperthyroidism

Take Home Points

• Memory Impaired may present to the Emergency Department for social, behavioral, medical, substance use or psychiatric reasons.

• It is important to identify which problem or problems is/are involved

• Does the patient need to be admitted/readmitted?

Contact Information

Leslie Zun, MD

Mount Sinai Hospital

1501 S California

Chicago, IL  60608

773-257-6957

zunl@sinai.org

Preventing Readmissions in those with Dementia Across the Post Acute Continuum

Nicholas Jauregui MD

Supportive Care Medical Group

October 16, 2014

Care Across the post- acute continuum

• Dr. Jauregui is board certified in Hospice and Palliative Care Medicine

• Medical Director: Supportive Care Medical Group, an active SNF and housecall medical group in Southern CA

NRPC So Cal Readmissions UpdateOctober 16, 2014