DispatchHealth - Advanced Care @Home

Who:

An 85-year-old woman who as chronic COPD with 3 inpatient hospitalizations in the past year for COPD exacerbations.  Has decompensated over the past two days with increased O2 requirement, cough, and fever.

Source:

Hospital ED evaluates patient confirms COPD exacerbation with an X-ray confirming pneumonia. In coordination with DispatchHealth Advanced Care team patient is admitted and onboarded to the AdvancedCare program

Care Coordination:

When Dispatch team arrives on site, they further risk stratify the patient for appropriateness with diagnostic capabilities on scene (physical assessment, lab- BMP, BNP, lactate, troponin, ECG, Xray). Patient receives daily hospitalist provider and twice daily RN visits, 4 days of IV antibiotics for pneumonia, and a high dose steroid taper, scheduled nebulizer therapies, and IV fluids.

PCP and pulmonologist engaged as a part of the care team up front. PT evaluates the patient in her home and works though safe bathing during her illness.  

As the patient returns to baseline respiratory status and no fever, she is transitioned to transitional phase of care to complete a 15-day episode of care daily. During that time, the patient’s steroid taper is adjusted and new prophylactic antibiotics added due to new symptoms in concert with the patient’s pulmonologist. 

Follow up appointments with PCP and pulmonologist are arranged and transportation is organized. Medication regimen and in-home management system is reviewed and adjusted. The patient’s scale for daily weights (she also has chronic CHF) was malfunctioning and “hasn’t worked in months” so a new one is arranged.  PT reviews conditioning that is commensurate with chronic illnesses. The patient and care team revisit and revise goals of care and advanced directives based on the patient and her daughter’s understanding of her chronic illness. 

We are able to treat patients ages 3+ Months and older.

Patients ages 3+ Months and older