Innovations and Efficiencies in Home-Based Care: HCCI Solutions Suite for NPHI Members-MJ Case Fillable Assessment and Plan

MJ Case Fillable Assessment and Plan

Pdf Summary

MJ Arzoumanidis, an 83-year-old male originally from Greece, had his first home-centered care appointment on December 3, 2021, after being discharged from the hospital for abdominal pain. MJ has been repeatedly hospitalized over recent months and has a range of significant health issues, including multiple ischemic strokes resulting in right-sided hemiparesis, Parkinson’s disease, heart failure with preserved ejection fraction, hypertension, type 2 diabetes (insulin-dependent), renal stones, benign prostate hypertrophy, atrial fibrillation, osteoarthritis in his knees, and open-angle glaucoma. He also has a large left inguinal hernia that has not been surgically repaired due to his fragile health condition.<br /><br />MJ's social context includes living with his niece, Olivia, who works part-time and provides his primary care but leaves him alone during work hours, leading to multiple falls. His wife, Sofia, has advanced dementia and resides in a care facility, causing significant financial strain.<br /><br />MJ’s health assessments highlight several areas of concern:<br />- He experiences fatigue and decreased appetite, accompanied by weight loss.<br />- His diabetes management is problematic with blood sugar levels ranging from below 40 to over 350.<br />- There's a combination of physical frailty, gait instability, and significant fall risk.<br />- His mental health shows signs of depression and occasional difficulty sleeping.<br />- He has dysphagia, likely related to Parkinson's, requiring a modified diet.<br />- He prefers not to be re-hospitalized and does not want resuscitation attempts.<br /><br />Current medication includes Lisinopril, Metoprolol, Atorvastatin, Warfarin, Tamsulosin, insulin (long-acting and rapid-acting), Carbidopa/Levodopa, and others for various conditions. MJ relies heavily on Olivia for medication management and mobility support.<br /><br />Patient preferences and goal discussions should prioritize his independence, safety, and emotional well-being while also addressing potential caregiver burden on Olivia. Enhanced geriatric, social, and fall prevention support could be crucial to improve MJ’s quality of life.

Keywords

home-centered care

multiple ischemic strokes

Parkinson's disease

heart failure

type 2 diabetes

atrial fibrillation

falls

caregiver burden

medication management

geriatric support