Sage Hospice and Palliative Care (Arizona)
Avoiding a Hospital Readmission Diagnosis:
Prostate Cancer Comorbids: UTI, GI bleed, Pneumonia, significant weight loss and seizures.
Brief Case History- Patient is a 72 year old Caucasian male who was admitted to SNF for rehab following a hospital admission for pneumonia, UTI and GI Bleed. Patient was hospitalized again during SNF stay to receive blood transfusion as his Hemoglobin was 7.
DNR/POLST Status: Wife agreed to not transfuse anymore.
Hospice Start of Care- Patient was enrolled onto hospice on 6/12/14 post discharge from SNF. Sage was able to find Patient a group home to reside in. As a result of meeting with the family, they acknowledged the severity of his disease process and what we could provide the patient to avoid sending the patient back to the hospital. Change in Condition – Patient steadily declined at the group home.
The hospice team along with the caregivers at the home kept a close eye on him to make sure he was comfortable. Upon admission, Patient was started on MSIR, Ativan and bowel care to ensure his comfort. Our nurse noticed a definite decline and change in Patient during her routine visit on 7/10/14 Actions taken – Our team reached out to the family of the Patient and explained to them that we believe he was entering the active stage of the dying process.
Sage team communicated with the Sage Hospice Medical Director and received permission from family to discharge all medications except for comfort medications. The Hospice team made daily visits. Sage team had visits from the nurses (both RN and LPN), Certified Nursing Assistants, Social Worker and Chaplain.
Outcome – Pt passed away peacefully on 7/13/14 at his group home.
Sage Hospice and Palliative Care has many examples such as this where our team approach coupled with education resulted in less than 10% percent of all our hospice patients being readmitted to the Hospital.
Sage Hospice and Palliative Care is located in Scottsdale Arizona and serves patients in Maricopa County. Our Interdisciplinary team is extremely motivated to provide quality care to reduce the number of patients going to the hospital.