Case Study #1: A 54 yo male admitted from the community w/chest pain and is in need of emergent heart cath. He coded, was intubated, and transferred to ICU. He was found to have severe multi- vessel disease with low EF 20-25%. After day #3 on vent, he was successfully extubated and is now encephalopathic and has been transferred to general med floor w/1:1 sitter in place He reported previously living alone and working part time. He is uninsured/not eligible for Medicare. No known NOK or DPOA for health care. Pt’s ID shows a home address. No known mental health or substance abuse Hx. He has no PCP and has not had any access for health care in the last 20+ years. Barriers: Strategies:

Case Study #2: A 50 yo woman found down at her AFC home. Hx of schizophrenia and substance abuse, 2ppd smoking hx in the setting of COPD, CKD, and DM. Was found to be in acute hypoxic respiratory failure and was put on HFO2. Complications during her hospital stay accelerated her CKD to ESRD and she began HD. Prior to hospitalization, she was her own legal guardian and had CMH services. Now mentation is waxing and waning, pulling at lines, agitated and “non-compliant”. AFC home cannot take her back and she is refusing Tx and medications, stating, “No, I don’t want that.” Per CMH, she has one adult dtr/only known NOK and who has limited contact with pt. At this time dtr is saying, “Do everything for my mother.” Barriers: Strategies: