NR 578 Week 7 Complex Geriatric Case Analysis Example

Complex Geriatric Case Analysis: The Plan Nine Specialist Recommendations Would Produce for an 88-Year-Old, Priced in Trips, Hours and Dollars, and the Plan That Survives

Student Name

College of Nursing, Chamberlain University

NR 578: Primary Care Management of Older Adults

Instructor Name

Month Day, Year

Complex Geriatric Case Analysis: The Plan Nine Specialist Recommendations Would Produce for an 88-Year-Old, Priced in Trips, Hours and Dollars, and the Plan That Survives

The Case

The patient is 88 and has six conditions: diastolic heart failure, atrial fibrillation treated with apixaban, kidney disease at stage 3b, wet macular degeneration affecting one eye, mild dementia and arthritis of the knees. The patient lives alone. The family has one driver, the daughter, a full-time dispatcher for a school bus company who has already used most of this year's leave. The patient no longer drives. A neighbor walks with the patient to the Saturday market.

The Plan the Conditions Would Ordinarily Call For

Cardiology every three months, with an echocardiogram each year. Nephrology every four months. Retina specialist every eight weeks for injections. Memory clinic every six months. Outpatient physical therapy twice a week for eight weeks, then a cardiac rehabilitation program three times a week for twelve weeks. Laboratory tests monthly for kidney function and potassium on the diuretic. Primary care every three months. Audiology yearly. Podiatry every ten weeks for nails, given vision loss.

This is the plan each guideline would support, written out so it is clear that the reduction below is a choice and not an oversight.

Pricing the Plan

Table 1

The Full Plan Priced in Visits, Trips, Caregiver Hours and Patient Cost per Year

The full plan comes to about 91 trips a year, nearly two a week, and about 230 hours of the daughter's time, which is roughly six working weeks. The patient's out-of-pocket cost is about $3,300 a year against a pension and Social Security income of about $2,100 a month. The physical cost to an 88-year-old with heart failure of getting dressed, down the stairs, into a car and through a waiting room is not in the table, but the patient described it: "Every appointment takes the whole day out of me."

Following each condition's guideline separately in older adults with several conditions produces regimens that are burdensome and full of interactions (Boyd et al., 2005).

The Plan That Survives

The reduction follows the three things the patient said matter most: sight, the Saturday market and living at home. Care aligned with patients' own priorities was associated with less treatment burden in a trial of older adults with multiple conditions (Tinetti et al., 2019).

Kept, in full: retina injections every eight weeks, because sight is the first priority and missed injections lead to lasting loss. Primary care every three months, as the coordinator of everything else.

Kept, changed: cardiology by video every six months, with the daughter setting up the laptop, because the heart failure is stable and daily weights are watched at home. Physical therapy at home, twice a week for six weeks, instead of outpatient therapy and rehabilitation, because home therapy can target the stairs and the walk to the market, which are the patient's goals.

Combined: laboratory tests drawn at the primary care visit every three months, and at the retina clinic in between if needed, rather than monthly trips.

Dropped: nephrology visits, with the primary care clinician following kidney function and calling nephrology if it changes; the memory clinic follow-up, since no treatment decision depends on it now; the yearly echocardiogram, since its result would not change management.

Kept by other means: audiology and podiatry at the same visit, twice a year.

How the Daughter's Time Was Counted

Each trip was counted from the time the daughter leaves work to the time the patient is home again: driving to the house, helping the patient dress and get down the stairs, the drive, parking, waiting, the visit itself and the return. For a 30-minute appointment the total was usually three hours. For the retina clinic, where the eye is dilated and waiting is longer, four. The counting was done with the daughter, using two recent appointments as examples, rather than estimated by me.

The Surviving Plan, Priced

About 18 trips a year, roughly one every three weeks, and about 55 hours of the daughter's time. Cost about $1,500 a year, most of it the eye injections. Minimally disruptive care, as May et al. (2009) describe it, means fitting treatment to the capacity of the patient and the family, and this plan is built to fit.

What the Patient and Daughter Said

Shown both plans side by side, the patient said of the full one: "That's a job, not a life." The daughter said she could not take two afternoons off a week for therapy without putting the job at risk. Both agreed with the reduced plan, and the patient asked that the eye injections never be the thing that gets dropped. The daughter asked for the lab tests to be done on the same days as the clinic visits wherever possible, which the plan now does.

Items That Lost Their Place, and Why

The yearly echocardiogram lost its place because the result would not change management in stable heart failure with preserved ejection fraction. Routine nephrology lost its place because kidney function has been stable for two years and primary care can watch it. The memory clinic follow-up lost its place because no medicine decision is pending and the diagnosis is agreed. Each could return if the underlying condition changed, and the primary care clinician holds the list of triggers in the problem list.

What the Reduction Risks

Fewer nephrology visits could delay a change in kidney care. Dropping cardiac rehabilitation gives up a structured program with benefits for heart failure. These risks are accepted because the alternative was a plan the household could not carry, which would have failed in practice. The plan will be reviewed with the patient and daughter at each three-month primary care visit, and any change in the patient's condition or the daughter's work will reopen it.

References

Boyd, C. M., Darer, J., Boult, C., Fried, L. P., Boult, L., & Wu, A. W. (2005). Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: Implications for pay for performance. JAMA, 294(6), 716-724. https://doi.org/10.1001/jama.294.6.716

May, C., Montori, V. M., & Mair, F. S. (2009). We need minimally disruptive medicine. BMJ, 339, Article b2803. https://doi.org/10.1136/bmj.b2803

Tinetti, M. E., Naik, A. D., Dindo, L., Costello, D. M., Esterson, J., Geda, M., Rosen, J., Hernandez-Bigos, K., Smith, C. D., Ouellet, G. M., Kang, G., Lee, Y., & Blaum, C. (2019). Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: A nonrandomized clinical trial. JAMA Internal Medicine, 179(12), 1688-1697. https://doi.org/10.1001/jamainternmed.2019.4235