1. Emergency Room Case Studies Diane Jackson, CM Geisinger

2. Ongoing CM Interactions CM interventions CM assessments Care Plan Movement to ongoing CM registry 2

3. Case Study 80 year old male Medicare Fee for Service CM managing prior to hospitalization Presented to the ER after a fall at home Adm. to hosp. with EKG changes MI R/O PT/OT being evaluated for next LOC IDT recommends rehab. stay Pt d/c to home day 4 with Home Health

4. TOC cont. Pt. is d/c Sat. evening CM contacts pt Monday Pt states that he has not be able to get out of bed. Friend gave him a ride home and he has been alone. They left him a drink and a sandwich.

5. TOC cont. Pt does not have any family Nephew POA in CA Home Health never received the ref. Lives on 1rst floor Has a dog

6. TOC cont. What’s the next steps for this pt.?