1. Risk Stratification & Intervention Follow Up Care for High Risk Patients Mary Beth Byrnes, MSN, RN

2. CARE MANAGEMENT PROCESS

3. Identify High Risk • Planned Care at Every Visit • Risk Assessment • Chart Alerts • Registry Reports • Notification from Hospital Admission & Discharge Notification • Self-Reporting

4. Risk Stratification • Age • Co-existing Health Conditions • Number of Medications • Functional Deficits • Non-adherence to treatment plan • Self-Care & Knowledge Deficits • Socio-Economic Issues • Support System • Utilization

6. Depression Risk Factors • Age • Co-Morbidities • Number of Medications • Significant Loss - Spouse, other significant family member, pet • Family Care Giver (Spouse or other generational dependent) • Social Isolation/Absence of Social Support • Fatigue/Sleep Disturbance • Chronic Pain • Functional Disability • Current Alcohol/Substance Abuse Disorder • Psychosocial Causes • Cognitive Distortions • Chronic Stress • Poor Self-Health Rating

9. Risk Factors for Falls • Age (>80 Years of Age) • History of Falls • Gait Dysfunction • Balance Dysfunction • Use of Assistive Devices • Visual Deficit • Medications (Hypotensive, CNS Suppressants) • Arthritis/Chronic Pain • Diarrhea/Urinary Frequency • Impaired ADL’s • Depression • Cognitive Impairment

10. Cumulative Risk • 0 – 1 Risk Factors – Seniors have a 27% chance of a fall each year • >4 Risk Factors – Seniors chance of a fall increases to 78% each year Tinetti: 1998

13. Instrumental Activities of Daily Living - IADL

15. Interventions • Evidence Based Guidelines • Functional Deficits • Knowledge Deficits • Socio-economic Issues • Barriers to Achieving Goals • Support System

16. High Risk Follow Up • Follow Up Date & Method Agreed Upon • Task List with Scheduled Reminder • Identify Goals Met – Unmet • Identify Barriers to Unmet Goals • Revise Plan • Set Next Follow Up

17. Case Study

18. 85 Year Old Male • Hypertension on 1 medication • Active and Working until 02/2011 • Fell on ice injuring ribs (1st Fall) • Hospitalized for abdominal pain with subsequent cholecystectomy • SNF • Severe Depression – Short Time in Mental Health System • 02/2011 to 01/2012 • Fell 3 more times – Out of State/County • Fracture Hip (01/2012) • Fell at Home 5 weeks after discharge (5th Fall) • Readmitted surgical repair wound dehiscence • Did not know family members until 01/2012

22. Low

26. Goals & Barriers • Self-Management Goals • Increase Physical Activity • Increase Self-Care Activities • Barriers • Difficulty Dealing with Functional Loss • Inability to Recognize Depression • Inability to Recognize Need for PT

27. Interventions • Inpatient & Outpatient PT/OT • Home Care • Evaluation of Home Environment – Fall Prevention • Medication & Psychiatric Counseling • Respite Care – 1 Week • Ongoing Outreach – Patient & Wife • Encourage Participating in ADL’s and Movement • Transitional Care Nurse

28. Questions?