Descriptive Name

Personal Health Communication, Transfer of Care, Coordination of Care.

Actor List: Attending hospital physician, patient, PCP, physical therapy

Scenario: Mrs. W, an 81 year old female, was admitted to the hospital following an emergency room visit for a fall and hypotension. Prior to her hospitalization, she had been followed by her PCP for osteoporosis and hypothyroidism. During her hospitalization, she was diagnosed with an acute ischemic left colon, diverticulitis, a rectovesical fistula, sepsis, and Type II diabetes mellitus. Once her condition stabilized, she was discharged from the hospital to home to rest in anticipation of surgery (anticipated to be 6 weeks after hospital discharge) for repair or her colon and bladder. Ms. W was able to ambulate to the bathroom, but unable to shower independently, shop for groceries, or cook meals and clean house due to weakness. Her son, who lives next door, planned to visit her daily at home and provide groceries. Mrs. W was instructed to follow up with the surgeon and with her primary care physician (PCP). The PCP had not been involved during the hospital episode, since the patient had been admitted through the emergency room to a hospital for which the PCP did not have privileges.

Information on Mrs. W's overall and functional status, along with information about the hospital stay were provided electronically to the PCP. They noted recent decline in ADL (now needs assistance bathing). The PCP called Mrs. W and requested that she schedule an appointment to evaluate overall health status and needs for follow up. During the appointment, the PCP evaluated Mrs. W's functioning, and determined that she was safe to remain at home with assistance from the family. He noted that she was at risk for falling and at risk of functional decline due to current period of inactivity and weakness. Recent decline in functional status and recent hospitalization signaled potential for functional improvement. Referral was sent to PT for exercise home program to be done pre-surgery and to be followed post-surgery for additional exercise program as required.