Panel: Preventing Readmissions in those with Memory Impairment

1. Panel: Preventing Readmissions in those with Memory Impairment October 16, 2014 Kim Butrum MS, RN, GNP: Moderator Jim McAleer MPA Leslie Zun MD Nicholas Jauregui MD

2. The Evidence • Memory impairing diseases are a significant area of concern in reducing readmission rates. NRPC So Cal Readmissions Update October 16, 2014

3. Utilizing Clinical Outcomes to Prevent Readmission in those with Dementia October 16, 2014 Kim Butrum MS, RN, GNP Vice President- Health Service Silverado

4. Use of Clinical Outcomes:The Silverado Experience • Through the collection of clinical outcomes over the past 18 years, Silverado has reduced both their 30 day readmission rate and transfer to the acute rate to industry leading levels. : NRPC So Cal Readmissions Update October 16, 2014

5. How do we do it? • Our culture • Education and training • Early identification and management of a behavioral or functional change • Alignment with strong partners for both extra support and palliative care/hospice care at different points of the disease NRPC So Cal Readmissions Update October 16, 2014

6. Don’t Prevent Readmission – Promote Community Retention… October 16, 2014 Presented by Jim McAleer., MPA President/CEO Alzheimer’s Association

7. Objectives • Know what community programs and services can make a difference • The Caregiver matters • Preventing readmission begins long before the patient leaves the hospital • Alzheimer’s Association Case Study NRPC So Cal Readmissions Update October 16, 2014

8. Dealing with Patients who have Memory Impairment in the Emergency Department October 16, 2014 Leslie S Zun, MD, MBA, FAAEM Chairman and Professor Department of Emergency Medicine RFUMS/Chicago Medical School Mount Sinai Hospital Chicago, Illinois

9. Objectives • Understand the role of the emergency department in evaluating memory impaired patients • To determine if the patient has a medical, psychiatric, substance use or behavioral problem

10. Case #1 • 64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history. • What further information is needed? • What to look for in the physical exam? • What testing is indicated?

11. Medical ClearancePurpose • Primary Purpose - To determine whether a medical illness is causing or exacerbating the psychiatric condition. • Secondary Purpose - To identify medical or surgical conditions incidental to the psychiatric problem that may need treatment.

12. Primary Purpose Etiology • Drug and alcohol intoxication or withdrawal • Medical • Hypoglycemia • Hyperthyroidism • Delirium • Dementia • Head Trauma • Temporal Lobe Epilepsy • Psychiatric

13. Delirium vs. dementia

14. Primary Purpose - Differentiate Medical from Psychiatric Etiology • Age >45 years old • Prior psychiatric/medical history • Abnormal vital signs • Physical examination findings • Cognitive deficits • Focal neurologic findings • New or different psychiatric complaints • Laboratories? • Advanced testing?

15. Case #1 64 year old female is brought to the hospital for manic behavior. Patient has multiple medical problems but no prior psychiatric history. • What information is needed? • Prior psychiatric history - none • History of medical problems – DM, HTN, CVAs • Use of drugs and alcohol - Denies • What to look for in the physical exam? • Vital signs – tachycardia & hypertensive • Focal deficits – right sided weakness • Signs of intoxication – Heightened consciousness • What testing is indicated? • CBC, electrolytes, UDS, alcohol level • EKG, CT scan head, CXR • Diagnosis – Delirium from Hyperthyroidism

16. Take Home Points • Memory Impaired may present to the Emergency Department for social, behavioral, medical, substance use or psychiatric reasons. • It is important to identify which problem or problems is/are involved • Does the patient need to be admitted/readmitted?

17. Contact Information Leslie Zun, MD Mount Sinai Hospital 1501 S California Chicago, IL  60608 773-257-6957 zunl@sinai.org

18. Preventing Readmissions in those with Dementia Across the Post Acute Continuum October 16, 2014 Nicholas Jauregui MD Supportive Care Medical Group

19. Care Across the post- acute continuum • Dr. Jauregui is board certified in Hospice and Palliative Care Medicine • Medical Director: Supportive Care Medical Group, an active SNF and housecall medical group in Southern CA NRPC So Cal Readmissions Update October 16, 2014