Need examples of medically complex nursing home patients

[ovnerati]

I am a new employee working for a health program that specializes in helping long term care clients return to their communites, either through assisted living, independant living, in their own homes, etc. I hope no one minds me asking about this on a forum for long term care patient's. I promise i'm not trying to steal LTC patients away (I love the nrusing home community--- just trying to provide options for those who want to go to other settings.... and can safely do so), but I wanted some suggestions from people who work everyday with patient who require nursing home level of care.

I am the programs first and only nurse to date. I was hired on with the specific purpose of managing a case load of medically complex clients. The program has never offered this service before and will only take patient's by referral. I have been asked to choose what criteria qualifies a patient as medically complex, and hence will be choosing what patients will be in my caseload.

The population I serve must already qualify for nursing home level of care, so a great majority already have multiple medical complications. Does anyone have suggestions on what type of situations would qualify a patient with nursing home level of care to be "exceptionally" medically complex? Initially I intend to take any patients who are referred to the program, but I would like to provide some general examples to my providers as examples of what a patient they refer might look like?

Any suggestions on criteria or examples of an "exceptionally medically complex" nursing home patient would be appreciated

[Nascar nurse, ASN, RN]

I am confused as to how these "exceptionally medically complex" patients will qualify for lesser services. My initial thought for medically complex would include those that need lengthy IV antibiotics, extensive wound care (stage III, IV - maybe wound vacs), trach care, brittle diabetics, etc.

[amoLucia]

Dialysis pts. Advanced COPDers.

I realize this isn't a technical medical diagnosis, but those who have little or no family support systems avail are seriously impacted.

Sounds like a very interesting position, Good luck.

Unstable enterally maintained pts, esp if diabetic, has wounds and wgt issues.

[JZ_RN]

indwelling permanent foleys or suprapubics, brittle DM patients, tube feeds, trachs, dysphagic, constant falls, fractures, osteoporosis, uncontrolled HTN, HF, ulcers and wounds, glaucoma, dialysis, contractures, aphasia, incontinence, hearing loss, blindness, nonambulatory, liver disease, chronic infections, BPD, BPH, TBI, etc. All just from thinking through the dx list for a few of our patients.

[Cheetopuff23]

Oopps wrong post.

[mlolsonny]

My Trifecta patient for complexity has had CVA, CHF, COPD. Add in DM, renal failure, Parkinson's, chronic infections, immunocompromise...