Descriptive Name

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

see Use Case Actors

This 75 year old man is being readied for discharge to his home following a four day stay in an acute care hospital for pneumonia. His past history is significant for COPD and diabetes mellitus. He uses a nebulizer and has home O2 and takes insulin which he has been taught to administer to himself. He lives with his wife who has some degree of functional impairment due to arthritis. His bedroom is on the second floor but in the past he was able to climb the stairs. They have a bannister on one side only. The visiting nurse service has been contacted and will make a home visit on the day following discharge. At this time they are insructed to assess his ability to administer insulin to himself unsupervised and to manage the stairs as well as take care of all his ADLs. Most of his IADLs are being managed by his daughter who lives three houses away.

Use Case 2

Age, gender, race: 72 year old, white male

Health state: Patient was electively admitted for a coronary artery bypass graft. He has a history of poor circulation, prostate trouble, hypertension, coronary artery disease, ulcers, gallstones, glaucoma, stroke, incontinence, and compromised kidney function. The patient takes the following medications: Minipress, Ditropan, Isordil, Bumex, Lanoxin, Zantac, enteric coated aspirin, Pericolace, and Betoptic eye drops. Length of stay was 15 days.

Developmental state: Patient reported a post high school trade education and is now retired. He scored a 10/10 on the mental status exam. He rated his own health as poor and his vision and hearing as fair. The patient has no dietary restriction and cooks and does all errands and housecleaning for himself. He rests while dressing due to shortness of breath. The patient reports claudication when walking but does not use a cane. He admitted to not being able to walk his dog and has significant weakness in his right arm and leg. The patient can drive but doesn’t travel unless it’s essential. The patient washes himself by sitting on a bucket. The patient wears briefs for incontinence and has nocturia. He recently stopped working due to leg pain/ shortness of breath. He avoids social activities due to incontinence. He scored 11 on the depression scale (16 or more = depression).

Family system factors: Patient is widowed and has two children that live in Florida and Holland. A nun visits and walks his dog. The patient reports no primary care giver but could call the nuns often during the day or evening if he needed assistance

Health system factors: Patient reported being hospitalized 3 times in the last 6 months and sought care from his own provider once during that time.

Environmental factors: Patient lives alone in a single-family home with his dog. The home has stairs and bathrooms on the kitchen and bedroom levels.

Socioeconomic factors: Medicare A and B with BC/BS supplement. His income is $18,000/year.