Who is lucinda's employer answers

Clinical Notes for:

Lucinda, Robert and Paul

Suggestion: To understand the coding for these chapters, it’s important for you to read through Chapter 7: Adult Integrated Case Management Using INTERMED- Complexity Assessment Grid Methodology and Chapter 8: Child/Youth Integrated Case Management Using INTERMED- Complexity Assessment Grid Methodology.

Lucinda (page 175-195)

Background:

· 37 y/o Mexican American woman

· Overweight

· Diabetic

· Referred by insurance reviewer due to overuse of medical services and after a provider sent a request in to have her gangrenous middle to removed

· Frequent medical procedures used/frequent hospitalizations/ER visits

· Last 12 months: 32 Rx filled from 6 different doctors

· Diabetic specialist (not an endocrinologist)

· Psychiatrists who Rx diazepam

· Surgeon

· # PCP

· Medical issues:

· Type 1 Diabetic since teen years

· 400+ Blood Glucose Levels (BGL)

· Gangrenous middle toe

· Chronic infections (skin and body)

· Ongoing fever off 104

· ALC 9.2 (snapshot of a diabetic’s overall blood sugar level over previous 3 months)

· Vision problems

· High Blood pressure (hypertension)

· Kidney disease

· Back and leg pain related to neuropathy

· Insomnia

Notes:

Focus on her readiness for change (VAS score)

Chart 10 in the supplemental packet is the Care Plan Development, which is also located on page 142, as a completed chart for Lucinda.

The questions (1-3 with follow-up questions) are in response to the Standard Questions. These are also listed in the Supplemental packet, in section E, page 13.

Make sure to review Ellen’s notes because they give you a lot of information and responses to the listed questions. Pay attention to Lucinda’s issues of: limited family/outside support network; family history of diabetes (mom is a diabetic and her own daughter is pre-diabetic and overweight); financial issues (uncertain about her job, has not been to work in last 3 months).

This is the worse 3 years in terms of her ability to control her diabetes- why? What change?

PCP can’t always see her, so she does see other providers who give her conflicting information.

· She is currently taking 10 different medications

· She checks her blood sugar when she feels bad but isn’t honest about her numbers due to embarrassment

· Misses her insulin because it’s unaffordable for her

· Has had diabetes management training in the past but has forgotten most of the information

· Often feels defeated in her management

· No treatment for depression but has been taking diazepam for her “nerves”

· Can’t knit due to her vision

· Not dating because of her health, weight, lack of interest

· Not working due to poor diabetes control

· Issues with being available for her children and their school related activities

· No help or support for ex-spouse/sporadic alimony/child support

Mental Health

· Loss of interest in things- moderate to severe depression

· Depression without SI/HI

· Generalized Anxiety Disorder without panic attacks- mild anxiety symptoms

· Family history of depression (mom and sister)

· Father history of alcoholism

Barriers to treatment

Lack of trust/communication with doctors- see page 183

See page 182 Table 12.4 for sample care plan with goals

See page 183 Reasons for medication non-compliance and other issues

1. Too complicated

2. Inconsistent directions

3. Too high of cost

4. Side effects- never discussed with her

5. Meds not seen as “working”

6. People told her she takes too many meds

Reasons for not following up with doctors

1. Too many visits

2. Not enough time/money

3. Mixed messages

4. Lack of trust

5. Family conflicts

6. Discouraged/depressed

Reasons for not exercising, following diet or completing BGL diary

1. Too much trouble

2. Doesn’t believes it works

3. Too hard

4. Doesn’t feel like doing it

Page 184 Lucinda picked her 2 top goals

Clinical: resolve middle ulcer on her toe without surgery

Functional: return to work

Plan for change (5)

1. Getting control of her diabetes

2. Good foot care

3. Treating depression

4. Coordinating provider involvement

5. Seeing if she can return to work under light duty

Pay Attention to the following:

Pg. 186 Table 12.5 Baseline scores IM-CAG

Pg. 187 Table 12.6 Baseline scores for ROM

Pg. 188 Table 12.7 Care Plan Development

6 week follow-up Table 12.8; 12.9 and 12.10

12 week follow-up Table 12.11, 12.12

Robert (pages -196-217)

Background:

· 49 y/o white male

· Works as an electrician

· Referred by employer’s disability management, was triggered for case management because of concurrent physical and mental health issues that are not be correctly treated while he is receiving medical services.

· Currently on short-term disability but might be a candidate for long-term disability

· Concerned he might not be eligible for disability support

· Has contact with his PCP 2x per month, who is a retired surgeon who does not really have Robert’s best interest in mind

· On 5 meds given to him by his PCP who might not be the best qualified to prescribe these meds

· Long history of anxiety with panic

· No mental health counseling

· Work performance has deteriorated over last 3 years

· Medical services being ineffectively used:

· Hospitalizations

· ER visits 2x per month for the last several months

· Prior to seeing current doctor, Robert was seeing a doctor he trusted, which meant his breathing and anxiety were under control. Dr. Couch only thinks that his chronic bronchitis is the problem and doesn’t believe in mental health issues and its impact on Robert’s health.

Robert is a high school graduate and went to trade school to become an electrician. He has approximately 20 years of experience as an electrician. About 12 years ago, Robert went through a bad divorce, so there is a lack of support. Both of his parents are deceased, siblings live in other states and he has very few friends. Robert does have 2 children but seeing them is also very sporadic, seeing them only 2x per year. Robert does not have any hobbies or activities that he currently participates in. He is also very inactive with attending church.

Contributing factors:

· Smokes 2 packs of cigarettes per day

· Lives alone and is a loner

· Worried about losing his job

· Used to enjoy going to sports bars to watch football, but no longer does this

· Family history of anxiety/depression

· Does not have a good relationship with Dr. Couch, his current PCP

· Used to enjoy model airplanes

Health Issues

**Confirmed medical issues are chronic lung disease, substance abuse, back pain pathology, R/O depression

· Chronic bronchitis- never told by Dr. Couch to stop smoking

· Chest pain- heart test show heart is normal, given diazepam for anxiety, biological father did die from heart disease

· High Cholesterol

· Headaches- when he drinks too much (2-3x per week, 2-3 drinks daily, +20 drink during the week) These headaches can be related to alcohol withdrawal symptoms

· Back pain- occasional

Treatment compliance- often misses his meds and his doctor appointments

Effects on his life:

· Homebound

· Anxiety makes breathing worse

· Panic attacks where he feels out of control

· Schedule appointments at 4 month increments but goes more often

· Dr. doesn’t understand his anxiety related to his breathing- and appears to not care.

Significant and Impactful Issues with Dr. Couch- doesn’t appear to be thinking of Robert and what is in his best interest. Doesn’t communicate well with Robert or with other potential providers; he’s very biased in his thinking and in his actions.

Pay attention to the following charts:

Exhibit 13.1 Depression Evaluation

Table 13.1 Anxiety Symptoms

Table 13.2 IM-CAG Baseline

Table 13.3 ROM Baseline

Care Plan Development- Baseline

Table 13.5 Week 6 Follow-up IM-CAG

Table 13.6 Week 6 Follow-up for Anxiety

Table 13.7 Week 7 ROM

Table 13.8 Care Plan Development Follow- Up

13.9 Week 17 IM-CAG follow-up

Roberts goals:

Clinical: to stop having spells off shortness of breath and chest pain

Functional: to go to sporting events with his friends.

Paul (pages 218-236) * be mindful that this case is from the Canada and is under that medical system)

· Paul is a biracial White and Pilipino male

· has trauncus arteriosis a congenital heart condition

· Has poor oxygen saturation

· Lack of school attendance

· Has blue/purple tint to lower extremities with significant clubbing of his fingers

· Managed with water pills and heart strengthening medication

· Cardiologists recommends using oxygen while sleeping but there is significant family push back

· Previous heart surgeries as an infant and again at age 5 to correct his cardiac defect

Referred for case management for several factors:

1. Health status has been clinically deteriorating in last 9 months

2. Significantly impaired, homebound without any schooling or peer interactions

3. Family reluctant to move forward with basic clinical cardiac investigations

Most likely will require cardiac surgery to replace Paul’s pulmonary artery conduit- no action does mean potential death

Paul’s parents are obstructing care-eventual ruling from CPS might be necessary since Paul’s condition is life threatening.

Parents are not open with Paul as to what is going on with his health- he does have a serious but potentially reversible condition. He has symptom progression and increased service usage.

Social:

Has a sister he looks to for support

Hasn’t done any schooling all school year

Enjoys computer games and watching tv

Parents do not encourage him to with his peers

Mom- disabled due to fibromyalga

Anxiety with panic attacks

Father- has a part time job as a finish carpenter

Issues with finances

Nervous (doesn’t think its anxiety)

Has chronic back pain/problems

Issues related to Heart Condition

· Tired much of the time

· Food sensitives

· Doesn’t ask questions regarding his heart condition, meds or doctors

· Heart surgery as a baby and again at age 5

· Bypasses doctor’s appointments to avoid conversation regarding heart catherization (parents)

· No one has really explained Paul’s condition to him and his parents

Mental Health Issues

· Learning difficulties resulting from cardiac condition on central nervous system function

· No traumatic life events

· Psychotherapy has been recommended but not followed through on

· History of anxiety with sleep difficulties since pre-school

· Worried about peer perceptions; embarrassed about school

· Family history of anxiety/depression

Concerns related to surgery

· At age 5, Paul has heart surgery in which his heart stop for several minutes and this caused some brain damage

· Sees a naturopath who is suspicious of medical interventions

· No mental health interventions

Clinical Goal: fewer breathing spells meaning reduced number of ER visits

Functional Goal: Getting out of the house meaning increasing number of times getting out of the house and engaging with his peers

Table 14.1 PIM-CAG Baseline

Table 14.2 ROM

Table 14.3 Baseline Care Plan Development

Table 14.4 Week 22 PIM-CAG follow-up

Table 14.5 ROM Week 22 follow-up