Case Study: Team Members & Their Roles

(adapted from the Rush Presbyterian – St. Luke’s Medical Center, Rush Institute on Aging Geriatric Interdisciplinary Team Training Project)

You are part of a home care team consisting of a geriatric nurse practitioner, an occupational therapist, a medical social worker, and a primary care physician. Other disciplines, services, and service providers (for example, physical therapy, speech pathology, respiratory therapy, home health aide, homemaker service, pharmacy, and nutritionist) are available to participate on your team but must be invited to a team meeting on an as-needed basis. The philosophy of your home care agency is that patients and/or family members are also members of the health care team in that they must be a part of setting goals and implementing any plans.

You have received a referral from a preferred provider organization (PPO) for Mr. Alex Green, a 64-year-old man with congestive heart failure, coronary artery disease, chronic obstructive pulmonary disease, hypertension, and diabetes.

Mr. Green has a history of presenting to the emergency room short of breath with fluid retention. He is sometimes admitted and sometimes treated as an outpatient by his primary physician.

Little has been done to break the cycle of treatment failure. The PPO wants to try another approach. Outpatient treatment will be authorized together, and bundled into one payment for the primary care physician, home care, and any other community-based care.

His current medications are as follows:

Diltiazem hydrochloride (Cardizem) 240 mg four times per day
Furosemide (Lasix) 40 mg four times per day
Theophylline anhydrous (Theo-Dur) 200 mg three times per day
Potassium chloride (K-Dur 20) 20 mEq every day
Glipizide (Glucotrol) 5 mg twice per day
Transdermal nitroglycerin system (Nitrodisc) every 4-6 hours as needed for chest pain

Mr. Green is on a low-sodium diet with 1500-ml fluid restriction, but he has not followed it in the past. Mr. Green lives with his daughter, son-in-law, and their three children, ages seventeen, nineteen, and twenty-three. He also has a son who lives with his family in the neighborhood within easy walking distance. The daughter-in-law likes Mr. Green, but doesn’t like his daughter and, as a result, refuses to visit him.

Emergency room staff describes the family as dysfunctional, unaware of the seriousness of Mr. Green’s condition, and "unwilling to be a part of his treatment plan". They believe that it is too much trouble to prepare a special meal for Mr. Green and that the emergency room is an appropriate place to bring him for treatment after he has eaten high-sodium and high-carbohydrate meals.

There are also several smokers in the family, and they refuse to limit their smoking or smoke outside. They say, "It’s our house; he is a guest. If he shouldn’t be around smoke, then he should go outside."

The outpatient plan of care calls for the following services:

Administer O2 @ 2 L/ nasal cannula
Check O2 saturation readings per oximeter every week
Draw SMA in 1 week
Check of weight, abdominal girth, and pedal edema (coordinate with primary care physician) daily
Teach low-sodium diet and restricted fluid intake
Evaluate home situation and family’s ability to participate in the plan of care
Teach energy conservation techniques
Test pulmonary function and obtain X-ray
Review and adjust medicine and improve compliance

The PPO will authorize $800/month to cover the outpatient care (physician office, home care, community care) charges and is allowing the providers involved to distribute the money in a manner that best supports a plan to provide care to Mr. Green and reduce emergency room visits.

Discussion
The questions central to this case include:

What are the issues involved in this case?
What disciplines should be involved in this case?
What can each discipline contribute to the care plan development?

The following figure is a case role map for Mr. Green’s case. This is one pictorial representation of how professional roles might overlap.