What Can You Do With Respite? - National Health Care for the
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Transcript What Can You Do With Respite? - National Health Care for the
What Can You Do
With Respite?
Leslie Enzian, MD
Medical Director, Seattle-King County Medical
Respite Program
[email protected]
It Depends Upon . . .
Local Resources
Bed availability
Facility
Staff disciplines
Funding stipulations
Mission/philosophy
Seattle King County’s
Medical Respite Program
Respite Focus
Short-term care for medically ill or injured homeless
patients
Goals:
◊ Resolution of acute medical process
◊ Bridge the gap between hospitals and shelters
◊ Window of opportunity to engage into services
◊ Initiate the process of lifestyle stabilization
◊ Decrease hospital utilization and costs
Potential Roles
Fill the service gap between hospitals
and shelters
Fill the service gap between hospitals
and clinics
Fill the service gap between SNF and
shelters
Acute Care
48 yo male presents to the ED with
alcohol intoxication and LLE cellulitis
and wound. Recommended to have 10
days of antibiotics treatment and daily
wound care.
What Can Respite Offer?
Monitoring for resolution of infection
Daily wound care
CD counseling and follow up
Mental Health Screening and care
TB Screening
Vaccinations
Housing Assistance
Primary Care referral
Seizing the Opportunity to
Affect Long-term Change
52 yo male referred for leg wounds.
PMH: Chronic lymphedema with
recurrent wounds, HTN, Schizophrenia
SH: Homeless since 1970’s, sleeps on
mat at shelter, resistant to engaging
Discharge timing?
63 yo female presents to
ED with nausea, chills and
generally feeling poorly
Can’t recall her medical history
Chart indicates h/o schizophrenia and
sarcoid disease
Off all meds, disengaged from all
care
SH: Staying in various emergency
shelters
Exam: 5X5cm irregular breast mass,
scabies rash, flat affect with delayed
responses to questions
Labs: Unrevealing
What Do You Do?
Schedule patient for outpatient
mammogram/breast clinic follow-up?
Admit patient for a inpatient work-up?
Admit the patient to Medical Respite
for a diagnostic work-up and
formulation of a treatment plan?
Subacute Care in Respite
Diagnostic evaluations for
disenfranchised patients
Pre-procedural care for colonoscopy or
elective surgery
Care during intensive treatment
regimens (chemo, radiation Rx)
Hospice care
29 yo male in respite for
twice daily wound care
Likes to sleep in, won’t get out of
bed for nursing visits--takes lengthy
cajoling
Nurse has 10 other patients to see
and feels lack of time
What Can You Do?
Give patient a warning then discharge next
time he declines to see the nurse
Team intervention to review admission
agreements, negotiate a behavioral contract
Impact: Tying up a bed from a patient that
might need, and cooperate with, care
Behavioral difficulties
Readmission criteria stipulations
Defined behavioral management process
Predetermined discharge dates
Venue for discussion and support with staff
52 yo male in respite for a
mandible fracture.
Client is angry and uncooperative
Client uses physically intimidating
postures and makes a physically
threatening comment to nursing staff
Staff and patient safety top priority
Safety in Respite
De-escalation training
Limit setting early
Safety measures: alarms, coordinated
show of support, room set-up
2 staff presence
Zero tolerance for racial or sexual
harassment
Venue for support, venting, discussion
46 yo male with EtOH
dependence, diabetes,
infected foot ulcers
Sleeps in the woods
In an actively abusive relationship
Never consistently engaged in care
Admitted to respite, received wound
care, continued to drink heavily, noncompliant with NWB, ulcers did not
heal
Referred for primary care, mental health
2 toe amputation recommended
Transported to hospital but never arrived
for admission
Few weeks later showed up from the woods
for a scheduled primary care appt.
Wound was larger, dirty and grossly
infected, was off diabetic Rx, intoxicated
Partial foot amputation
Hospital calls to refer him back to respite
What Do You Do?
Decline admission because of non-
compliance
Readmit to respite?
Respite Course
Drank daily across the street from respite
Attended most respite nursing visits for
wound care, functioning in group setting,
blood sugars not wildly out of control,
mostly complied with NWB
Supervising nurse daily reports of drinking
Pt not discharged from respite, eventual
shelter discharge after considerable wound
healing
Focused Expectations
Nursing felt pt sabotoged health and
respite care unsuccessful
Admission was great success! Patient
did not get wound infection/leg
amputation
Often can’t effectively fix maladaptive
lifestyle issues, but can prevent serious
complications from an acute process
How to Support Successful
Process?
Difficult to witness self-destructive
behavior
Clarify case goals with team
Weigh impacts of various decisions
Offer venue for venting, discussion,
support
Training on harm reduction
Treatment Compliance
Patient won’t take BP meds
Patient discharged on a new diabetic
medication regimen and won’t follow it
Do you contract then discharge these
patients? What is primary Rx goal?
How can you maximize success and impact?
Educate, engage, refer for primary care
54 yo female with history of
BAD with COPD exacerbation
Off psych meds, unwilling to engage in
mental health care
Not taking Rx prednisone and antibiotics
Patient is agitated, angry and
uncooperative with respite care and
unresponsive to behavioral contract
Patient is discharged by respite due to
behavior
The Patient is referred again
in 2 months for COPD
Did you put the patient on a respite
bar list?
If barred, how long would bar last?
Could the patient be put on a
“Readmission Criteria” list stipulating
that she in stable on psychiatric meds,
engaged in mental health care and
contracts to cooperate with care?
45 yo male with pneumonia
and heroin dependence
The patient admits to continued daily
heroin use
Patient is behaviorally appropriate in
the respite space
Attends all nursing visit except for one
What Are Your Options?
Perform a urine toxicology screen and
discharge patient if positive
Perform a urine toxicology screen and
contract patient to maintain sobriety,
discharge at next (+) utox
Continue to engage patient in discussion
around use and options for treatment
Implications of these various options
52 yo heroin dependent
patient referred for
abscess wound care
Pt underwent operative drainage of
abscess and has a 20 X 10 X 5 cm
buttock wound
Patient was on high dose methadone
and prn oxycodone in the hospital
Hospital prescribes 30 pills of
oxycodone at discharge
Questions? Potential problems?
How will patient’s
pain be managed?
Do you ask the hospital to Rx higher
dose and quantity of narcotics at
discharge? (Implications)
Do you ask hospital team to initiate a
pain service consult?
Do you accept patient and send him to
an ED or clinic for pain meds day 2?
42 yo male with heroin
dependence referred
for pneumonia.
Respiratory symptoms for 1 month
Vital signs are stable and he is Rx
antibiotics
He is independent in his ADL’s
Do you have any questions for
hospital team prior to respite
admission?
Pneumonia Referrals
Where is the infiltrate? Clinical
course? Does TB need to be ruled out?
HIV and TB
CD4 counts < 200, CXR can be normal or
infiltrate could be in any location
Consider rule out TB prior to respite
admission unless clinical course clearly
acute pneumonia
39 yo female, poorly
controlled DM in clinic.
Erratic BG monitoring
Erratic BG readings ranging from 50’s
to 400’s
Respite can offer:
Diabetic education
Feedback to provider on diet/compliance
Titration of meds to avoid complications
68 yo male in need of hip
replacement surgery
Needs 2 wks of SNF post-surgically
Surgeon won’t do surgery unless pt has
a recuperative place to go after SNF
Nursing home won’t take him unless
there is place for him to go.
Potential niche for respite
What Can You Do
With Respite?
Acute medical care
Care for chronic uncompensated or
decompensated problems
Facilitate diagnostic evaluations and followup
Pre-procedural care
Care during treatments with associated
morbidity (XRT, chemotherapy)
Care for clients not eligible for nursing
homes or are being discharged from SNF
What Can You Do
With Respite?
Successfully care for behaviorally
complex patients
Care for homeless high utilizers
Linkage to primary care, CD treatment,
mental health treatment and housing
to affect long-term lifestyle
stabilization
“Respite has been a God send for me.”
Dave with a skin infection