Inclusion Criteria

Patients with care management needs in order to remain in their homes.
- Examples: Referral to home health, home nursing and diabetes education, transition from Independent living to Assisted living, coordination of family services etc
Patient is MOST LIKELY to be able to go home within 24 hours with care management / rehab interventions.
Patient needing SNF that is VERY LIKELY to have dispo within 24 hours**
No other complicating or acute illness
Clearly documented Goals of Care and Medical Proxy

Exclusion Criteria

Any patient anticipated to need facility placement that will take > 24 hours to complete**
Patients needing guardianship
Unsafe home condition / Not eligible for discharge to shelter
Pending APS inquiries
Complex care management needs
Dementia with Behavioral Disturbances

** Most insurances take > 24 hours to make a SNF dispo. If care management can confirm that SNF Dispo is likely within 24 hours, than CDU is OK. **

Fall Precautions
Delirium Precautions
Medication
- PRNs
  - Antiemetics - Zofran
  - Pain - Acetaminophen
  - Heartburn - TUMS/Maalox
  - Agitation - Quetiapine 25 mg QHS PRN
- Scheduled
  - Melatonin 3 mg QHS
  - Constipation Prevention - PEG + Senna
- AVOID
  - Please reference BEERS Criteria for inappropriate medications in older adults
  - In Particular, Benzodiazepines, Zolpidem, Diphenhydramine
Consider PharmD Consult for polypharmacy / medication management
Care Management Orders
PT eval and Treat Orders
Order "OT Cog Eval" ONLY after careful consideration of consequences / in conversation with Care Management and PT. This evaluation can sometimes cause more harm than good.

Disposition

Unstable vital signs or worsening clinical condition
Significant lab or imaging abnormalities
Patient unable to take PO medications or able to safely care for self in home environment.
Patient unable to ambulate

Learning Links:

Page updated

Google Sites

Report abuse