Case Presentations
New Patient:
One Liner: In one sentence describe the patient and why they are being admitted.
Utilization History: How many ED visits, Admissions, and Days between admissions in
the last 6 months.
More Medical History: Additional medical issues that may come into play.
More Social History: Other social barriers that may pose a problem – family
relationships, social supports, transportation needs, housing needs, insurance, etc.
Goals: Top Identified goals from the first visit – does not have to be all encompassing
Action Steps: Immediate steps you plan to take. Include date of next meeting.
New Patient Example:
One Liner: Mr. X is a 65 year old patient who has many admissions for COPD in the
setting of chronic unstable housing.
Utilization History: In the past 6 months, he has been in the ED 5 times and admitted 7.
Most recent days between admissions is 5.
More Medical History: Mr. X also has hypertension.
More Social History: Mr. X. is a past IV Drug User and is on methadone maintenance
therapy for the past ten years. He has a wife who is chronically out of the picture and
when he is out of the hospital he lives with his sister. He has trouble arranging his own
transportation to appointments. Mr. X has Horizon Medicaid.
Goals: The goals for this patient include
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Getting a PT consult for evaluation for sub-acute rehab
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Further evaluation of homelessness and potential housing options
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Set patient up with Logisticare for transportation
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When a stable place is secured, work on home O2
Action Steps
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Speak with nurse/SW about PT consult and potential sub-acute rehab stay
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Call social services for information about his case re: housing
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Make logisticare appointment
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Expected discharge not for 1 week. Visit in hospital at bedside in 4 days to
determine discharge plan and what appointments are needed post discharge.
Daily Patient Check-ins
One liner: In one sentence describe the patient and why they are being admitted.
Recent visit information: Include information regarding patient’s current medical and
social state
Goals / Action Steps: Include when your next meeting with the patient is, what goals you
have for that meeting and how those goals will contribute to reducing admissions /
adding to overall goals. Include any tasks you will complete outside of the visit.
Daily Patient Check-in example:
One Liner: Mr. X has many admissions for COPD in the setting of chronic unstable
housing.
Recent Visit information: He’s recently been hospitalized due to a COPD exacerbation.
He needs to go to sub-acute rehab but refuses. He plans to return to his sister’s home
when he is discharged. We talked to his nurse about homecare / home O2 consult. We
have some potential housing placements but all require a state-issued ID which he does
not have.
Goals/Action Steps: We plan to visit the patient tomorrow at his sister’s home. We will
schedule an appointment to go for his ID and follow up about outcomes of homecare
and what appointments he will need. Outside of the appointment, we will call logisticare
to set up transportation. When Mr. X. is more stable, we will give him training on how to
use logisticare.
Daily Patient Check-in example 2:
One Liner: Mr. Y. had many admissions for diabetes. He is now stabilized at a nursing
home.
Recent Visit: At a recent visit, he signed paperwork so payment will run smoothly for his
long term stay at the nursing home.
Goals/Action Steps: We will see the patient weekly until discharge for social visits.
Discharge expected in 3 weeks.
Daily Patient Check-in example 3:
One Liner: Ms. Z has admissions for pain and for asthma exacerbations caused by her
crack cocaine use.
Recent Visit: Unable to find her.
Goals: We plan to do a ride-by on Thursday; if we cannot be found, we will send her a
letter discontinuing her care.
Graduated Patient:
One Liner: In one sentence describe the patient and why they are being admitted.
Utilization History: How many ED visits, Admissions, and Days between admissions in
the last 6 months.
Discussion of our intervention: Explanation of goals, our interactions with the patients,
successes and failures.
Discussion of patient readiness for chronic disease self-management – review of the
health coaching list.
Discussion of patient hand-off to PCP
Patient’s response to exit interview questions / lessons learned
Graduated Patient Example:
One Liner: Mr. X is a 65 year old patient who has many admissions for COPD in the
setting of chronic unstable housing.
Utilization History: Prior to our intervention, he had been in the ED 5 times and had been
admitted 7 times in the last 6 months. Since our intervention, he’s been admitted 15
times and has only been out of the hospital for 4 weeks.
Discussion of our intervention: Mr. X had goals of stable housing and we had the goal of
stabilizing his COPD. During our intervention, we worked to get his state issued ID and
begun filling out paperwork for an apartment at Northgate II. At every encounter in the
hospital, we encouraged him to go to sub-acute rehab or to long term housing but he
refused. We also get him hooked up with global options. In regards to stabilizing his
COPD and pain medications, we accompanied him to his pcp at virtua but have yet to
get him to pain management.
Discussion of patient readiness: Patient’s cousin has helped him make appointments but
he has not taken many steps to care for himself.
Discussion of PCP Hand Off: Patient’s case presented to PCP who scheduled an
additional appointment with the patient.
Patient’s Response to Exit Interview Questions / Lessons Learned:
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