Nancy Lilienthal

NRS221
1/24/18
Case Management

Primary diagnosis: Injury from fall, weakness, instability

Outcome: Strengthen stabilizing muscles and decrease fall risk, heal prior fall injury to chest
(which will strengthen overall posture/core strength and reduce risk of another fall)
Components (personnel, supplies, durable equipment, etc.): SNF (nursing, CNA, dietary),
PT, OT, home health nursing, FWW  cane, pill sorter, wound dressings, camera, measuring
tape, nutritional information for foods (generalized list of common items for patient to use once
home), grabber
Expectations of components in order to reach outcomes/goals:
SNF:
 LPN/RN- continue to monitor wound dressing from fall injury/location of chest tube
(removed), adherence to medication regimen to aid with healing/infection prevention and
prevent further secondary complications, pain management, assessment of overall
physical/emotional/psychological well-being, modifications to care plan as needed, and
referrals to resources as necessary
 CNA- encourage independence w/in safety limits established by PT assessment, use of
gait belt with all activities until released by PT, walk pt to and from dining and encourage
participation in facility activities, maintain fresh water pitcher and encourage fluid intake
 Dietary- provide options that promote healing while remaining low in sodium (3g/day),
high in protein, high fiber, level 3 dysphagia advanced texture.
 PT- strengthen stabilizing and structural muscles, instruct on proper technique/use of
FWW eventually graduating to use of a quad cane or ‘c’ cane, teach proper techniques of
obstacle navigation (stairs, turning corners, sitting in/standing from chairs), improve
flexibility to obtain appropriate upright posture (pt is hunched over/leaning forward),
educate pt on exercise regimen tailored to his ability and needs
 OT- entering/exiting automobile and shower/tub, proper clothing (non-restrictive but not
excessively loose), dressing technique, non-skid footwear that secures to feet (no
footwear w/out heel to keep shoe from flopping), home check prior to discharge (no
rugs/mats not secured to floor), hand railings in appropriate locations (stairs/shower),
non-slip strips in tub and on exterior steps, shower chair, grabber use for out of reach
items
Home Health RN: Assess patient’s ability to navigate home including stairs, sitting/standing,
walking. Review medications/adherence (use of pill sorter to be reloaded weekly in a supervised
manner with nurse while reviewing what the meds are for, what the dosages, and side effects
are). Generalized home inspection checking for fall hazards and educating pt on how they are a
problem to prevent recurrence of hazardous situation. Check vital signs and review patient’s
overall well-being since last visit noting any inconsistencies or declines and considering causes
and solutions to improve pt health/safety. Assess any new wounds/injuries and document with
 Nancy Lilienthal
NRS221
1/24/18
Case Management

photographs and measurements (per consent). Likewise, re-evaluate any prior wounds and their
status including documentation. Review patient’s eating habits and access to appropriate foods-
seek resources if needed (food bank, government supplementation (EBT) and help establish a
menu for the week based off patient’s choice of foods with discussions about food likes/dislikes
and how they pertain to his suggested dietary restrictions.
Frequency:
 SNF- minimum 30 days with re-evaluation at days 15 and 25 before discharge. Medicare
will cover 1st 30 days 100%, days 31-90 are $40/day deductible. PT while at SNF 5
x’s/week @ 30 min/visit. OT while at SNF 2 x’s/week @ 30 min/visit.
 Home Health Nurse- 2 x’s/week for one month, graduating to 1 x/week until patient can
demonstrate independent management of medications and confident safe navigation of
home environment and teaches back safety measures to prevent future hazards or
compromising situations.
Anticipated time necessary to achieve results is approx. </= 60-90 days post hospital
discharge. Regular evaluations at each interaction will determine progress achieved and extend
or shorten the goal timeframe as necessary.