I'll be glad to field that question for you:
In my case, we review the medical record extensively. We look at physical status as well as functional, cognitive and psychosocial status. These are all issues that impact health. So for example:
83 y/o lady was recently in the office for a fall, suffered only a wrist sprain. Extensive chart review reveals that she has been in the office 3 times in a 12 month period for falls. Each time, her injury was treated and she was sent home. She has never had a bone density test, vitamin D level was low and she has not had her eyes checked in over a year. She has diabetes and the last foot exam was abnormal. No podiatry follow-up. She lives alone and still drives. Oh yeah and she's on Coumadin. None of her providers have put this picture together.
The patient is contacted by phone and asked about the circumstances of her falls. She minimizes it and states she is just clumsy. If she were to fall and unable to get up, she has no way to call for help. No emergency response. Her son does call about once a week. She states it is important to her to remain independent and live in her own home. Obviously, falling and breaking a hip or cracking her head and getting an intracranial bleed is a threat to that goal, this is a disaster waiting to happen.
In collaboration with the rest of the team, we then create a care plan that centers on her fall risk. Interventions recommended to the provider are:
-bone density testing to check for osteoporosis or osteopenia; treat if found
-vitamin D supplement; calcium supplement
-annual eye exam
-follow-up with podiatry re: potential neuropathy; assist to schedule if needed
-gait and balance assessment by the provider to determine if she needs physical therapy; order if needed
-check for orthostatic hypotension; adjust meds if found
-stop Coumadin until falls are addressed
-personal emergency response system; ask son to check in with her more often
-teach about home environment and safety; ie throw rugs and wall rails, lighting, etc
At 3 month follow-up, it is found that she did indeed have a gait and balance problem. PT has made significant progress with her, she is now using an assistive device. She has an emergency response button and took the throw rugs out of her bathroom and kitchen. Bone density test found osteopenia so calcium supplement is sufficient for now.
6 months later, she remains safe in her own home. No additional falls and she reports that she actually feels more confident and has started going to a senior center 3 times a week. The patient met her goals, did not need bedside nursing care since we kept her out of the hospital and I never laid eyes or hands on her.
