Settings of Care Board Game

Vignettes

Case #1

• 90 y/o, lives alone in home; fell, couldn’t get up• No family in area; has close neighbor who

checks on her daily and found patient on floor • Sent to ED; no fractures, rhabdomyolysis,

infection • Dehydrated, soft tissue musculoskeletal

injuries, pain, and unsteady gait• Admitted to you because unsafe to go home• In hospital; working with PT; pain & gait better• What is the ideal discharge setting for her?

Case #2• 84 y/o widower • Cognitive deficits (MMSE 22/30)• Lives in senior independent living building• One daughter lives nearby and checks him

regularly (but not daily)• Patient diabetic, treated with OHGA• Admitted: Hyperglycemia and worse CRI• Insulin added with accuchecks (at least daily)• Daughter can give insulin and assist with

accuchecks, but can not do this every day• Patient has some financial resources• What is the ideal discharge setting for him?

Case #3

• 69 y/o female• Lives alone in low income housing; no family • Hospitalized with recurrent MRSA in 2nd Total Knee

Replacement• Knee joint removed; needs antibiotics • Allergic to vancomycin• ID suggests daptomycin daily IV X 6 weeks• Currently ambulating by pushing herself around in

a wheelchair• What is the ideal discharge setting for her?

Case #4• 78 y/o male living at home with family• Severe Parkinson’s disease and some dementia• Admitted for 3rd episode of aspiration pneumonia

in 3 months• Responding to therapy, but hospitalization is

traumatic for him• Family feels that, after this episode, patient should

not be re-hospitalized if he gets pneumonia again• Family says they couldn’t handle having patient at

home if he aspirated and got short of breath. • Patient’s health insurance is Medicare / Medicaid• What is the ideal discharge setting for him?

Case #5• 87 y/o female with baseline cognitive deficits

(MMSE 22/30)• Lives in house with multiple extended family• Falls and sustains pelvic fracture• In hospital, is able to work with PT• Improvement in endurance and gait is slow• Family and patient have a long standing

agreement that patient will never go to a “nursing home”

• What is the ideal discharge setting for her?

Case #6• 85 y/o female living alone in apartment • No family in area• Slowly progressive cognitive decline; now

with paranoia • Eats and drinks little because she fears

people are trying to poison her• Admitted with dehydration• Now hydrated and stabilized on psych meds• She has no significant financial resources• What is the ideal discharge setting for her?

Case #7• 75 y/o lived in own home caring for frail

spouse• Long hospitalization due to complications

after CABG, including respiratory failure• Off ventilator, has PEG tube• Beginning to eat• Slowly works with PT (sits on edge of bed)• Has a large sacral pressure ulcer requiring

wound vac therapy• What is the ideal discharge setting for her?

Case #8

• 80 y/o female lives alone in own home• Admitted with first episode of CHF• Cognitively intact and only other medical

problem is poor vision • One daughter who lives in the area, but

frequently out of town on business• What is the ideal discharge setting for her?

Case #9• 82 y/o widower• Lives in senior independent housing• Admitted; 3rd episode of CHF, felt secondary

to poor medication compliance• Patient admits he often forgets to take some

of his medications or he gets them confused; MMSE 21/30

• Has 2 children, but both live more than 30 miles away

• Patient has some financial resources• What is the ideal discharge setting for him?