History
JT Andrews is a 79-year-old male who presents to the ED for shortness of breath. He has a history of congestive heart failure (CHF), hypertension, and benign prostatic hypertrophy (BPH). His current medications include lisinopril, metoprolol, and furosemide. He has had one week of mild shortness of breath but no chest pain, fever, or cough. He describes a 2 lb weight gain.
Exam & Disposition
On exam, his vital signs are: BP 155/92 HR 65 RR 12 T 37C (98.6F) 96% RA. He has a normal physical exam except for very soft rales in his lung bases (click audio file to play lung sounds) and trace pitting edema in his lower legs.
His ED physician, Dr. Hayden, orders a chest X-ray (mild central vascular congestion, no pulmonary edema), EKG and labs (all normal), and a single intravenous dose of furosemide. Dr. Hayden asks you to “do your SDOH screen thing” before he discharges the patient to home.
You quickly review Mr. Andrews’ Epic notes which reveal two hospitalizations in November and three ED visits in December.
Social Needs
As you dig deeper, you determine that Mr. Andrews hasn’t been monitoring his weight at home (you encourage him to purchase a scale at the Walmart near his home – he states he can afford a $10-$15 digital scale – you print out a specific model at his Walmart and call ahead to ensure it is available).
He also discloses that he has been eating several times a week at the corner store – sausage/egg for breakfast, lunch meat sandwich with potato chips for lunch, and pasta with tomato sauce for dinner. He loves Doritos at all times of the day. When asked, he states there are simply no grocery stores with healthy foods within walking distance. Plus, he doesn’t have a car.
You press him about seeing his primary doctor for follow-up, and he reports missing several scheduled appointments due to a lack of transportation. He has to rely on his extended family for transportation.
Plan
A reasonable plan to manage his issues:
Food Insecurity (& Diet)
- MANNA
- Meals on Wheels (for 60+ years old).
- Print out CHF diet recs (e.g., Nutrition Tips at Kaiser, Lexicomp "heart healthy diet," etc.).
- Farm to Families – Supplies North Philadelphia families with boxes of wholesome fresh produce or fruit at a reduced cost; it also provides food and nutrition education.
Transportation
- Ask about health insurance – Cigna and Keystone First may have transportation options for primary MD visits.
- CCT shared ride program may help with visits to grocery stores and primary MD visits.
- If he has Medicaid – Could use Logisticare (only to doctor appointments).
- Always consider connecting older patients (65+ years) to PCA – Can help with all of the above.
Other
- Please mention the option of case management/home health to this sort of patient – He is a high utilizer with readmissions; it is important to have a Social Worker aware of his health needs.
- High utilizers should = referral to multidisciplinary team.
- Case management can arrange home healthcare and durable medical equipment (DME) ordering if he requires home oxygen.
- Either call his primary MD office to let them know about the latest ED visit or send them an Epic “staff message.”
Remember to look for resources under "Top 5," JeffHope spreadsheet, and CE Resources spreadsheet. Aunt Bertha is a great option for searching by zip code.
Readmission diagram