Mr. Jones is a 64 year old male with a history of CVA and CHF. While he has been stable for many years, he as recently struggled to stay out of the hospital due CHF exacerbations followed by 2 weeks of inpatient rehabilitation. My name is Dr. Smith and I am Mr. Jones' primary care provider. Please assess him for a medical home model of care. He has experienced a recent fall and I believe he isn't following his prescribed diet.
Thank you Dr. Smith for the referral. We completed a case conference on June 30th in reference to your patient and will be sending our staff to see him later today. Our goal is to reduce re-hospitalizations and keep him safe at home. We believe we can offer him care under his Part A Medicare benefit.
Mr. Jones, I am here to asses your needs for healthcare as well as manage your care along with your RN here in your home. The RN will also educate you on your diet. We will be providing you an easy to open pill box that the nurse will set up for you on a weekly basis with your medications for morning, noon and evening time. We will develop a CHF diary and educate you on signs and symptoms of a CVA. I will also obtain orders from Dr. Smith for a PT/OT eval, a social worker, and a mental health specialist. These servcies will be covered under your Medicare home health benefit. We will also determine if an athletic trainer can assist you under your private insurance.
Mr. Jones, I am a medical social worker. I am here to let you know that you currently have Medicare and Part A will cover your home healthcare. A home health care episode is set up after your initial visit from the ARNP and a unique care plan is developed and set for 60 days. Additionally, we can go over your private insurance and see if we can give you any additional services such as an athletic trainer. I have also discovered that your home is in a Food Desert so I will be showing you how to use the virtual grocery store and getting you set up with a program that can deliver food to your home. I can also help you get set up with other community resources.
Good news Mr. Jones. We have determined your private insurance will cover my athletic training services once you are discharged from home health. I will see you in 60 days! I have submitted my treatment plan to your physician for approval. Once your pain is under control we can start with proprioception and functional exercises.
Mr. Jones, I am your mental health specialist. I am certified to evaluate you for depression if you're interested. I am also really good at talking and assisting people through the grieving process. If you are found to be depressed, I can tell you that working on your depression will also help you battle your CHF. During my time with you I will be utilizing motivation interviewing as it has been an effective method for many of patients.