IPE Case: Mrs. Trainwreck ANSWERS
Objectives
-Identify members of the healthcare team and the roles they play in patient care
-Determine appropriate recommendations for a patient upon discharge
-Analyze financing options for patient care
Patient Scenario
Mrs. Trainwreck is a 68 year old female patient who has been admitted to the hospital for
shortness of breath, dizziness, and severe abdominal pain.
Upon arrival, the following was found during initial evaluation:
- Necrotic tissue in R foot
- Swelling in both lower extremities
- Right sided weakness
- Diarrhea and severe dehydration
Her past medical history and past surgical history includes:
- Type 2 diabetes for 15 years
- Minor CVA 2 years ago (causing her minor right sided weakness)
- L THA in 2008
- L3-4 lumbar laminectomy in 2010
- Posterior spinal fusion of L5-S1
- Obesity
- CAD
- Hypertension
- Former smoker
- Asthma
- It’s also noted in medical records that the patient does not monitor her diabetes well.
Mrs. Trainwreck has a L total knee replacement scheduled this week however, with her current
condition, her doctors need to decide whether to reschedule the surgery for another time. The
patient lives with her husband in a 2 story home. Her husband is not home at all times and Mrs.
Trainwreck is very impulsive. She has children who can come occasionally and help her. Her
bed and bath are on the 1 floor. She has 5 steps to enter with a rail on the L side. The patient
has been using a single point cane for short distances in her home and needs a walker for
longer distances. Mrs. Trainwreck is currently receiving acute physical therapy to address her
endurance deficits, bed mobility and right-sided weakness.
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Healthcare System
Mrs. Trainwreck was admitted to Number-One Hospital, part of the BEST healthcare system,
located primarily in the Richmond, VA area. The first hospital was opened in 1876 as a not-forprofit organization. Today it stands as one of Richmond’s largest healthcare systems, serving
the community and partnering with sports teams and organizations around the city, including the
Flying Squirrels, the Kickers, the Richmond Marathon, and the University of Richmond.
The network consists of 5 acute care community hospitals with approximately 200 beds. The
hospitals offer the following services:
· Joint restoration
· Acute Care Medicine
· Burn Unit
· Neonatal Intensive Care
· Trauma Unit
· Cardiac Surgery Intensive Care Unit
· Neurology
· Orthopedics
· Women’s Health
· Cardiac Surgery
· Transplant Unit
· Pediatrics
· Respiratory therapy
· Radiology
· Inpatient Rehabilitation
· Oncology
· Adult Psychiatry
BEST includes 22 outpatient rehabilitation centers offering the following:
· Accent Reduction Program
· Balance/Vestibular
· Robotic Assisted Gait Training
· Orthotic Training
· Prosthetic Training
· Cognitive Retraining
· Work Conditioning
· Spine Stabilization
· Lymphedema
· Neuromuscular re-education
· Driving Evaluation
· Therapeutic Exercise
- Wound Care
Additionally, the network has 5 skilled nursing facilities, home health services, 2 outpatient
dialysis centers, and 10 physician offices, among others. The network also offers 2 centers for
wellness and metabolic health in the area, providing weight and diabetes management support.
The hospitals and outpatient locations provide educational classes, support groups and health
screenings for community involvement.
Patients are able to book appointments, request prescription refills, pay medical bills, and
message their health care providers via a convenient website/app (mybest.com). The website is
also able to provide estimates of health care costs in advance so patients can confirm their
insurance coverage prior to the procedure.
BEST participates with many government and commercial insurances including:
· Aetna
· Cigna
· Tricare
· Virginia Medicaid
· INTotal Health
· Innovation Health
· Anthem BlueCross BlueShield
· CareFirst BlueCross BlueShield
· Medicare (A and B)
· United Healthcare
· Behavioral Health Plans
· CorVel
· Virginia Health Network
BEST offers many options for financial assistance as well, including discounts for self-pay
procedures, a state-sponsored indigent care program, the Virginia Coordinated Care Program,
and Medicaid.
Discussion
Assume Mrs. Trainwreck has Medicare. Upon admission to the ED, a variety of consults are
ordered. What sort of consults would you expect for Mrs. Trainwreck? Why?
-Neurology (for her weakness and dizziness)
-Radiology (scans to check for blood clots or tumors)
-Internal Medicine/Cardiology/Diabetes (cardiac symptoms and diabetes management)
-Surgery (whatever is available for her emergent situation)
-Infectious Disease/Dermatology (for her wound)
and eventually, PT, OT, nutrition, social work, and possibly clergy.
A large abdominal aortic aneurysm is detected via MRI. Mrs. Trainwreck is sent to the OR for
emergency surgery. The surgeons have two options: 1) open abdominal surgery with a six
month recovery and 2) a less invasive endovascular approach with a short hospital stay
followed by a three-month recovery. What factors will affect Mrs. Trainwreck’s ability to
choose which surgical approach is taken? Describe some scenarios in which she has no
choice.
Factors include: surgeon availability, her ability to wait or not, which options insurance may
cover, her preference. IF insurance will only cover one option or if there is no surgeon available
for a certain option, if she cannot wait for surgery, she will have no choice.
Mrs. Trainwreck is in stable condition after surgery. Her dehydration and diarrhea have been
resolved medically. Her shortness of breath and dizziness are gone, but she is still in a lot of
pain, though this is attributed to her recent surgery. Due to her history of diabetes and smoking
there is concern about both her stomach and foot healing. What sort of services might
improve her wound’s healing? Are these available within BEST? Will her insurance likely
cover them?
-The center for wellness and metabolic health available within BEST which provides weight and
diabetes management support may help her control her diabetes.
-Wound care may directly debride the wound to improve.
-A hyperbaric chamber may increase her body’s ability to heal.
On day five of her recovery, Mrs. Trainwreck has not made significant progress towards her
goals. She still requires moderate assistance for transfers and is too weak to safely ambulate
independently with a walker. Do you think Mrs. Trainwreck is able to safely return
home? Describe some possible discharge destinations and their availability within
BEST? Who on the healthcare team might provide input on possible discharge
destinations? For each destination, what type of medical services will she need to
receive?
No, Mrs. Trainwreck is not able to safely return home given her compulsive nature and the fact
that her husband or children are unable to provide 24 hour supervision and care.
Possible discharge destinations include:
- Skilled nursing facility (5 available within BEST): she will need her condition (post surgery and
comorbidities) to be closely monitored, as well as wound care, and PT/OT to regain some
independence
- Home with home health services: she will need a home health nurse to monitor her condition,
provide wound care and administer medications. She will also need Home PT/OT to restore
functional mobility
Members of the healthcare team who might provide input on possible discharge destinations
include PT, OT, social worker, patient care manager, doctors and nurses.
Mrs. Trainwreck’s TKR has been rescheduled for three weeks in the future. Where might Mrs.
Trainwreck be at this time? How will Mrs. Trainwreck get to the hospital for this surgery if
she cannot drive while still in recovery? Who would help her coordinate this?
Mrs. Trainwreck may be in a skilled nursing facility at this time and she may be transported to
the hospital for surgery by a transport van from the nursing facility or by ambulance. The social
worker/case manager would help her coordinate this.
Mrs. Trainwreck may also be living at home at this time and she may be transported to the
hospital for surgery by ambulance or some other type of patient transport service. The patient
may need to schedule this transportation, but a social worker/case manager can offer guidance
and offer suggestions of transportation services that are available.
Mrs. Trainwreck’s surgeons are concerned that she won’t heal well from her TKR due to her
poor health. They would like for her diabetes to be better managed and for her to maintain a
weight loss and exercise program. What sort of professionals might help her achieve these
goals? Will their services be available through BEST?
Professionals that could help Mrs. trainwreck achieve goals listed above: Dietician to help with
proper nutrition choices for weight loss, Diabetes Coach to teach and encourage monitoring of
diabetes and making good diet choices, Physical Therapist for strengthening, conditioning, and
establishing a home exercise program, Personal Trainer/Fitness instructor to work individually
with Mrs. Trainwreck at the gym or instruct classes that she may enjoy participating in.
Excluding personal training/fitness instruction, all of these services are offered through BEST.
The centers for wellness and metabolic health may be excellent resources for Mrs. Trainwreck,
providing coaching on diabetes and weight management. Additionally, they may provide
referrals for personal trainers and gyms in the area. Physical and Occupational therapy are
available through BEST in their various outpatient, inpatient, and skilled nursing facilities, as
well as through home health services.
Due to Mrs. Trainwreck’s poor health, age, sex, and history she thinks she will be unable to
exercise with a trainer. She had fantastic physical therapists and would like to continue working
with them to improve her fitness. In what circumstances would “physical therapy to improve
her fitness above baseline” be covered by insurance? What sort of fitness program or
physical therapy would be most appropriate for her?
If the physical therapy provided is used to allow the patient to perform the ADLs and IADLs,
physical therapy can be used to improve a patient’s fitness above baseline. In this scenario, the
physical therapy would be covered by insurance. After her stint with inpatient rehab or home
health PT, Mrs. Trainwreck would benefit from an outpatient orthopedic clinic that has
community wellness programs. These programs are run by physical therapists so they can
make sure Mrs. Trainwreck is able to complete her physical training with the appropriate
consultation and supervision.
Mrs. Trainwreck is worried about how she is going to afford all of these services. What
resources are available in the BEST system to answer her financial questions? How
does having Medicare affect her access to care?
The mybest.com website provided by the BEST system is a resource Mrs. Trainwreck can use
to estimate cost in advance and confirm whether or not it will be covered by her insurance.
BEST also offers financial assistance options and participates with Virginia Medicaid. Medicare
Part A, B and D should help cover her hospital stays, procedures and prescription medications
with some exceptions. There is a Medicare therapy Cap of $1920/calendar year, which may limit
the amount of rehabilitation services she can afford. The BEST financial office is available to
offer any information on financial assistance programs, and to answer any questions regarding
payment.
Mrs. Trainwreck is talking to her granddaughter who is interested in working in the healthcare
field and she is trying to recall all the different people who have helped care for her since her
admittance to the ED. Make a list of the health care professionals that have been a part of
Mrs. Trainwreck’s journey so far.
Paramedics, Triage Nurse, Nurse, Nurse Practitioner, Physician, Physician Assistant, Patient
Transporter, Physical Therapist, Occupational Therapist, Social Worker, Case Manager, Care
Partner, Surgeon, Pharmacist.