You Be the CP: Case Studies of Complex MIH Patients – EMSWorld

Posted: September 19, 2020 at 3:57 am


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The patients seen by mobile integrated healthcare and community paramedic programs are among the most complex out there. While CP leaders have now devised a standardized framework for evaluating their needs, much remains subjective when individual medics sit down to rate individual patients.

Wednesdays EMS World Expo session on MIH-CP patient management challenges provided an opportunity for providers from different departments to collaborate on a pair of case studies and work jointly through that evaluation framework, known by the mnemonic CPS MERITS. The idea was to benefit from each others experiences and ideas.

CPS MERITS was developed by Dan Swayze, PhD, COO of the Center for Emergency Medicine of Western Pennsylvania, and Anne Jensen, EMT-P, special projects coordinator for San Diego Fire-Rescue. Jensen led Wednesdays session with Faith Applewhite, NRP, from the Santa Fe (N.M.) Fire Department. They were joined by community paramedic Shawn Percival, who works with Jensen in San Diegos Resource Access Program (RAP), and Santa Fe mobile health paramedic Ramos Tsosie, a colleague of Applewhites in Santa Fe Fires Mobile Integrated Health Office (MIHO).

Both departments use CPS MERITS, but to galvanize the exchange of ideas, they crossed services to work through the case studies, with Percival and Applewhite leading the first and Tsosie and Jensen the second.

The mnemonic, described in a 2019 EMS World article by its creators, helps providers understand the nature and severity of the patients condition, establish a baseline to measure change over time, and provide a road map for care planning. It stands for:

Each of these dimensions is measured as threatening (in need of immediate assistance), unsustainable (working but not for long), sustainable (not ideal but could work long-term, such as a person adapted to homelessness), or ideal. Once rated they can be prioritized for action, with threatening and unsustainable situations taking natural priority.

Percival described a mid-60s female living in a city neighboring San Diego who, during their 18-month collaboration, called 9-1-1 400500 times in her own town and another 80 in San Diego.

He judged her clinical and psychological situations threatening: She had dementia with severe behavioral and cognitive impairment, and often sought Tylenol for arthritis pain in her wrist. Shed overdosed on it previously and didnt understand the danger of taking too much. She was triggered by family, and while her dementia made any help difficult, her problems seemed mostly behavioral, Percival said.

Meals, records, and income werent a problem (ideal), but the other four domains were all unsustainable: Family (social) was tiring of her repeated 9-1-1 calls and false claims of abuse. She was housed (environment) but not always supervised and thus could go out for Tylenol. (Shed also leave the gas stove on, which, while caught each time by her husband, could raise the situation to threatening, Percival noted.) Her calling 9-1-1 for transportation couldnt be sustained, and taxi companies had begun refusing her service over repeated nonpayment. And while she could basically self-care (skills), the stove issue and persistent nonunderstanding of Tylenol overdose dangers left that unsustainable too.

Two threatenings, four unsustainablesa tough patient for sure. The proposed big-picture solution was conservatorship, and her daughter was willing to assume it. But a barrier popped up: Despite the dementia, she was deemed to have the capacity to consent. The countys patient advocate suggested a special conservatorship with dementia powers, so now Percivals team is working with the hospital social worker to navigate that application process.

A lesson here: Sometimes you need multiple plans. You never know where its going to lead you, said Percival. You think youve reached the end goal, then the goal posts have been moved on you.

This patients unsustainable dimensions also intertwine with the conservatorship, but it is rarely used, hard to get, and COVID has slowed court processes. The team is currently awaiting a decision.

Tsosie said his department has found the CPS MERITS framework useful but added an extra legal domain after missing some patient arrests.

The patient he described was a 41-year-old male, mostly homeless, who lived part-time with extended family in the pueblos outside Santa Fe but frequently traveled to town with his mother. In the 18 months theyd worked with him, hed overdosed on opiates 16 times they knew of and maybe more. Hed also been hit by motor vehicles several times and had TBI and a leg injury that caused chronic paina big driver of his substance use.

Obviously the ODs made his clinical situation threatening. Psych was too: The TBI caused problems with impulse control, Tsosie said, and it was hard to get this patient to appointments. Drugs and alcohol were easily available.

Meals and transportation were judged sustainable, but the income domain rose to threatening because the patient was focused on getting disability to the detriment of any other efforts at self-help.

All other dimensions were unsustainable: Family (social) was loyal, but he couldnt use at the pueblo so often didnt stay. In town (environment) he often slept on the streets. He wanted disability but was unable to collect the necessary paperwork (records). He had good social skills, but lack of impulse control often led to aggression. And while he had various court issues (legal), complying with such requirements wasnt usually a priority.

Three threatenings, five unsustainablesanother tough one. But while this patient clearly needs help, his repeat overdoses forced the team back to a much more basic posture: just trying to keep him alive. They gave naloxone to him and his family and took him repeatedly to a harm-reduction clinic in an effort to habitualize his use of it. His income domain was also difficult to address: Hed applied for disability and been denied twice, so they connected him with a representative to help, but he continues to miss appointments.

Beyond that the team has worked to stay in close touch with the patient, keep a feel for his baseline, and offer support and positive social interactions. Tsosie described those interactions as oxygen to those in such challenging circumstanceswithout them, he said, its hard for you to think and feel and navigate the world.

Efforts to help these patients are ongoing. You may face some equally as difficult. There arent right or wrong answers with CPS MERITS, and the point isnt that you should agree with all the ratings here. It can be subjective and vary with community resources. The lesson is theres value in sharing multiple perspectives and working through such assessments with additional sets of eyesthats something community medics often need.

John Erich is the senior editor of EMS World.

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You Be the CP: Case Studies of Complex MIH Patients - EMSWorld

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