1. CASE STUDY: MR. XY Created By: Josh Simons

2. History 75 year old Caucasian male HPI: patient fell in his home, reporting loss of sensation and weakness in his right side Primary Dx: Left thalamic stroke with right hemiparesis Functional Ability PTA: independent PMH: degenerative joint disease and back pain Medications: Plavix, Flomax, Mevacor, Lisinopril, Metformin Social history: patient is married, supportive wife, no history of alcohol or tobacco abuse Comorbidities: Hypertension, Type II Diabetes Mellitus Primary Insurance: Medicare

3. What Services Does Mr. XY Need? Acute Care Hospital Neurologist Nursing Pharmacy PT/OT Inpatient Rehab PM&R Physician PT/OT SLP Nursing Home Health PT/OT Skilled nursing

4. First Stop: Acute Care Hospital After fall, wife drove Mr. XY to Inova Fairfax Hospital and delivered him to the ER Primary goals Treat any injuries sustained from the fall Diagnose the cause of the weakness and sensory loss experienced by the patient Administer and prescribe appropriate medications as needed Begin rehabilitative services to help patient return to function Services administered during visit Neurologist exam, nursing, physical therapy, occupational therapy, imaging, social work, pharmacy Expected length of stay: 5-6 days

5. Qualifications for Medicare Acute Care Medicare Part A covers hospital services, including semi-private rooms, meals, general nursing, and drugs People with Part A are covered when all of the following are true Doctor makes an official order which says you need 2 or more midnights of medically necessary inpatient hospital care to treat your illness or injury and the hospital formally admits you You need the kind of care that can only be given in a hospital The hospital accepts Medicare The Utilization Review Committee of the hospital approves your stay while you’re in a hospital Because of Mr. XY’s fall and neurological disorder, he fulfilled all of the above requirements. Inova also accepts Medicare Part A.

6. Second Stop: Inpatient Rehab Inpatient rehab facility also located at Inova Fairfax Hospital Transportation not an issue for Mr. XY as transport team can escort him to the rehab center Primary Goals Further education on disease process and steps to overcome it Ambulation training with least restrictive assistive devices Prescription of at-home DME UE ADL training to facilitate prior functional activities Speech training to facilitate clear, enunciated speech Services Administered During Inpatient Rehab Physical Therapy, Occupational Therapy, Speech, Physiatry, Nursing Expected Length of Stay: 2-3 weeks

7. Qualifications for Medicare Inpatient Rehab Medicare Part A covers most the cost of care Will only cover up to 60 days of care For Medicare to pay for stay in an inpatient rehab center, the doctor must certify that Mr. XY needs Intensive PT or OT (at least 3 hours per day, 5 days per week) At least one additional type of therapy, such as speech therapy or prosthetics/orthotics Full-time access to a doctor with training in rehabilitation, including at least three visits per week Full-time access to a skilled rehabilitation nurse Because of the nature of Mr. XY’s functional impairments, his doctor certified that he required all of the above services; thus he is covered through Medicare

8. DME Prescription Because Mr. XY still has difficult ambulating without an assistive device, the PT from the inpatient rehab facility will have prescribed him with an appropriate device for at-home use Training with the device is taught at the inpatient rehab facility More than likely a cane or walker will be prescribed depending on level of standing balance both static and dynamic Medicare Part B covers medically necessary DME that the doctor prescribes for use in home Patient pays 20% of Medicare-approved amount

9. Third Stop: Home Health Once discharged from Inpatient Rehab, Mr. XY returns home to continue care through home health Transportation home delivered by wife Inova VNA Home Health provides a multidisciplinary team to help Mr. XY become functional in his home Primary Goals Assess home for potential fall risks Provide safe strategies for navigating around home with least restrictive device Ambulation training and strengthening Continued UE ADL training to return to prior functional level Home Health Services Administered PT, OT, SLP, skilled nursing, social work Expected Length of Services Administered: 3-4 weeks

10. Qualifications for Medicare Home Health Under the care of a doctor Doctor must certify that Mr. XY needs one or more of the following Skilled nursing, PT, SLP, OT Home health agency must be approved by Medicare Must be homebound, and a doctor must certify that Mr. XY is homebound. To be homebound means the following: Leaving home isn’t recommended because of medical condition Condition keeps Mr. XY from leaving home without help Leaving home takes a considerable and taxing effort Mr. XY meets these requirements as he is not fit to leave home due to his neurological condition, and his wife is not able to consistently drive him to outpatient services

11. Future Steps? After Mr. XY has been discharged from home health services, his function should be significantly better than when he was in the hospital At this point, Mr. XY should be able to navigate around his community safely To address any additional deficits, Mr. XY could enlist the services of a certified fitness professional, preferably one who specializes in neurological dysfunction Fitness professional could provide a workout program which would not only help regain function, but also decrease his comorbidity of hypertension With these continued services, Mr. XY should be able to engage in all prior functional activities