Online Appendix 2: Comprehensive Care Plan example
Mobile Vulnerability Team
Department of Ambulatory Care and Community Medicine
Rue de Bugnon 44
CH-1011 Lausanne
Tel: +41 79 556 44 18
NAME, PATIENT
Date of birth (DOB); Sex; Medical Record Number (MRN)
Ms. XX, DOB:01/01/1900
MRN: 111111
Esteemed colleague;
The above named patient was evaluated by the Mobile Vulnerability Team from __ to __.
TREATMENT REQUESTED BY:
Dr. XY from the Emergency Department on date xx/xx/xxxx.
EVALUATION ACCORDING TO THE 5 AXES OF VULNERABILITY
The request for treatment from the Mobile Vulnerability Team team was determined from indicating an accumulation of 7 vulnerability criteria shown in the following 5 axes of vulnerability in this ED frequent user (5+ visits/12 months):
1)SOMATIC DETERMINANTS
Acute/Chronic Severe Illness
Complex medical treatment
Pregnancy or neonatal period
Somatic comorbidity
Medication or treatment non-adherence
Restricted mobility/physical handicap
2)MENTAL HEALTH STATUS
Psychiatricco-morbidity
Anxiety disorder
Psychotic disorder
Somatoform disorder
Dementia
Depressive disorder (including threat to self or others, suicidal ideation or suicide attempt)
Personality disorder
Post-traumatic stress syndrome
Psychological development disorder
(including mental retardation…)
3)BEHAVIORAL DETERMINANTS
Active dependency or abuse (alcohol, tobacco,drugs, gambling, prescription medicine, etc)
Risky sexual behavior
Problems linked to contraception or termination of a pregnancy
At-risk situation or danger for children
Interpersonal and/or physical violence (including domestic violence, harassment, sexual abuse, etc)
4)SOCIAL DETERMINANTS
Complex/difficult family situation
Complex/difficult financial situation
Insufficientor absence of health insurance
Immigration problem or residency status instability
Social exclusion or isolation
Inadequate or lack of housing
Inadequate or lack of work/school/social activities
Difficulty understanding/insufficient knowledge of common language
5)HEALTH CARE CONSUMPTION
Frequent use of emergency services at the CHUV-PMU or at other care providers
Care seeking from multiplemedical providers
Difficulty in relationships with caregivers and/or providers
Lack of a primary care physician
GUIDANCE AND STEPS TAKEN
1)SOMATIC DETERMINANTS: Patient XX known to have sarcoidosis,accompanied with Löfgren’s syndrome, which was diagnosed in 2012. In March 2013 the progression of her sarcoidosis led toneurosarcoidosis with a vasculitis of the left positioned cerebral artery and brain inflammation that was seen treated with 5 doses of Remicade (from April to October 2013). Relating to this condition, the patient demonstrates chronic tension headaches. Furthermore, Patient XX suffered from epilepsy during her adolescence, from age 14 to 16. On a surgical level, she received treatment for a cervical disc hernia, as well as treatment for bilateral carpal tunnel. Finally, she underwent an operation for an ovarian cyst in 2008.
2)MENTAL HEALTH STATUS: Patient XX suffers from severe depression that she developed during the same period as the neurosarcoidosis. Patient XX also explained that she suffered a lot during her childhood. It is noted that Patient XX had a psychotic decompensation under the influence of steroids (in April 2013) and was getting better aftercortisone had been regressively administered.
3)BEHAVIORAL DETERMINANTS: Patient XX doesn’t consume alcohol, tobacco or drugs. However, she was a victim of physical and mental violence from her mother during her childhood. In addition, she was a victim of physical violence from her husband during their first years of marriage. The violence from her husband later stopped when his consumption of alcohol was reduced.
4)SOCIAL DETERMINANTS: Patient XX was born in Portugal and grew up alongside a brother and sister. As previously mentioned, she explained having a difficult childhood. Both she and her sister were victims of physical violence from their mother. Patient XX was placed in a boarding school and, along these lines, she says to have received very little love during her childhood. It is noted that Patient XX never spoke of her father during our meetings. Currently living in Switzerland with her husband and their two children (23 and 10 years old, respectively), she has permanent residency. Having no professional formation, Patient XXhas worked in industrial cleaning or in factories. Before becoming ill, Patient XX applied for unemployment benefits. She worked, under the job placement of an agency, for a month. Then, in April 2013, she was put on sick leave because of her illness. Since this leave she has been receiving state aid (APGM). However, she is at risk of losing her right to this aid shortly. Financially, she and her husband have taken on burdensome debts that put them in a difficult situation, as their income has decreased with the sick leave of Patient XX. These difficulties could worsen whenher state aid runs out.
5)HEALTH CARE CONSUMPTION: We met Patient XX as part of a Swiss National Research Foundation study on patients who frequently use emergency health services. Prior to our treatment, she had presented 5 times to the Emergency Department at the Lausanne University Hospital during a 12 month period, with each admissionrelating to her chronic tension headaches.
OBJECTIVES AND PROPOSALS
During the treatment period, the Mobile Vulnerability Team objectives were to evaluate the needs and resources of Patient XX in order to offer her a place to be heard and, at the same time, to work on an administrative level to accompany her toward social assistance so that she could receive long term social aid. To date, the objectives of care have been reached and Patient XX benefits from medical monitoring and social assistance. In agreement with this outcome, we have closed the patient’s case.
NETWORK OF PROVIDERS
Doctor XYPrivate OfficeOffice phone number
Attending Physician
Doctor XYPsychiatric ServicesOffice phone number Resident Physician Lausanne University Hospital Mobile phone number
Rue de Bugnon 44, 1011 Lausanne
Ms. XXPsychiatric ServicesOffice phone number
Social WorkerLausanne University Hospital Mobile phone number
Rue de Bugnon 44, 1011 Lausanne
Doctor XXNeurology ServicesMobile phone number
Resident PhysicianLausanne University Hospital
Main hospital building
Rue de Bugnon 46, 1011 Lausanne
Please do not hesitate to contact us for further information, our best regards,
Signatures:
Dr. XXDr. XXMs. XX
Supervising PhysicianChief ResidentMobile Vulnerability Team Nurse