Donna went above and beyond for a patient recently discharged from an inpatient admission. During Donna's telephonic discharge assessment she recognized the patient was having difficulties coordinating his care and was unfamiliar with his medication regimen post-discharge. Donna went above and beyond to visit the patient at home to help coordinate care between the PCP, anti-coag clinic, nephrology specialist, and the patient's preferred pharmacy.
Donna quickly recognized the patient and caregiver were not able to participate in a medication review over the phone and set up a home visit with the patient to review his medications and discharge instructions. While in the home, one of the patient's specialists called regarding his BP medications. Donna was able to help communicate with the specialist and the patient to ensure the patient was taking the correct medication and dosage. In addition to ensuring the patient understood his BP medication, Donna taught the patient how to use his in-home MP monitor.
While in the home Donna reviewed all medications with the patient and set up his pillbox for him and helped organize all of his medications in a way that was easy for his caregiver to remember and taught her how to fill the pillbox every week.
During this visit, Donna recognized the patient was currently taking Coumadin but was not currently being managed by the SMG Anti-Coag team. Donna worked with the provider to place the referral and with the Anti-Coag team to get the patient an appointment first thing Monday AM.
Donna went back to the patient's home on her day off (Saturday) to ensure the patient filled the one missing medication and provided education on how/when to take the medication to the patient and caregiver.