Question

Scenario 9: Burns/Subdural Hematoma

You are caring for a 66-year old male on his 21st day inpatient following a motorcycle accident sustaining a subdural hematoma, multiple facial fractures, and third degree burns to his left lower extremity. He is participating with physical and occupational therapy, but still requires significant medical management including IV antibiotics, IV fluids, and IV analgesics. The patient required mechanical ventilation initially, but now has a tracheotomy with supplemental oxygen. He is receiving total parenteral nutrition due to his facial injuries restricting oral intake.

The patient’s wife is at the bedside and states that she is thankful that her husband has come so far, but realizes he still has a long way to go. She states that since the patient is now able to participate in therapy, she hopes that he will begin to progress at a much faster rate. She states, “I know he cannot stay here in the hospital forever. What is the next step in his recovery?”

Knowing that the patient is progressing and that his length of stay is increasing, the case manager wants to discuss the patient’s discharge plan with you as well as other interdisciplinary team members.

Past medical history:

Migraines

Home Medications:

Propranolol ER 120 mg daily, Amitriptyline 25 mg daily, Topamax 50 mg twice daily

Allergies:

None

Insurance:

Medicare

Social history:

The patient is married and lives with his spouse in a two-story dwelling. He denies tobacco or drug use, but reports drinking beer socially – about 2-3 once weekly. The patient denies having any services or durable medical equipment in the home.

Family history:

The patient’s mother died at the age of 68 with breast cancer. Her father is still living and has heart disease and asthma. His maternal grandmother had a stroke around age 70. The patient denies any other significant family history.

1. If the patient’s condition remains unchanged, what services may benefit this patient post-hospitalization?

2. What factors are considered for an interdisciplinary team to determine which type of post-hospital service is best for the patient?

3. Which post-hospital services would the patient be eligible for under Medicare guidelines? Would the patient be eligible for these services if he/she were not a Medicare patient?

4. What requirements are there for the patient to be eligible for transition to post-acute services? (For example, required length of stay, documents, tests, etc.).

5. What are some common mistakes in coding or charting for this patient that would jeopardize the hospital's reimbursement?

6. What challenges are identified as barriers to a safe discharge home?

7. Describe the discharge planning information that the nurse could initiate upon admission and be sharing with this patient/family to improve patient outcomes.

8. Discuss the significance of stay, acuity index, comorbidities, and allowable days in planning this patient's care.

9. In designing a plan of care for this patient, what additional information do you need from the patient/family to complete your assessment and begin a plan of care? (For example, additional financial support, resources, functional assessment, learning barriers, special needs, etc.).

10. What are some common barriers to discharge that might increase the patient’s length of stay or jeopardize a smooth transition to the next level of care?

Answer 1

1.Some of the services which may benefit post hospitalisation are

• Nursing service for medication and tracheotomy care
• Physiotherapy or physical service to help in early mobilisation and regaining musculoskeletal strength
• Personal support worker service to do basic activity or daily activity
• Occupational therapy service to help him recover and get back to work

2.Some of the factors which are considered for an interdisciplinary team to determine the type of care are

• The disease condition and its progress
• The supportive persons in the family to care in home

3.The patient may get the following service

• Skilled nursing service
• Home health services
• Patient will be eligible if where not medicare patient under HHA

4.The requirements for the patient to get post acute services are

• The provider clearly describing the need of post acute service stating the patient is home bound. They need acute care to get recovered from illness