Palliative Care Differentiation at Providence
The team at Providence collaborates weekly on patients to ensure optimal symptom management, while improving overall quality of life for their patients and families!
- Chronic Illness Support
- Improved Quality of Life
- Advanced Care Planning
- Symptom Management
- Team Focused Collaboration
- Increased Patient
- Satisfaction
Medically Complex Case Study
77-year-old female admitted to Providence Rehabilitation and Healthcare Center from HUP Cedar, where she initially presented with ambulatory dysfunction, bilateral lower extremity pain and swelling. Etiology of swelling was venous insufficiency. Hospital course complicated by hypomagnesemia and hypokalemia s/p repletion. Course further complicated by UTI s/p antibiotic course. Past medical history significant for HTN, CHF, COPD on home O2, OSA, SCLC s/p radiation and SBRT, diabetes and hypothyroidism. The patient was transferred to Providence Rehab for continued medical optimization and ongoing therapy services.
Interventions:
Medication Management – Lasix, Aspirin, Atorvastatin, Nifedipine, Synthroid, Spironolactone
Close Monitoring of Vital Signs including Pulse Ox and Accu-Checks
Close Monitoring of Labs including CBC, BMP and Magnesium
Respiratory Therapy Interventions:
Followed closely by our Pulmonologist, Dr. Francis Brahmakulam and our in-house full-time Respiratory Therapist. While in-house, she remained stable from a respiratory perspective. Continued with supplemental oxygen, CPAP at HS, Advair, Incruse Ellipta and Albuterol as needed.
Cardiology Interventions:
Followed closely by our Cardiologist, Dr. Richard Seifert for history of HFpEF and HTN. Patient with continued lower extremity edema and medicine regimen was optimized.
Therapy Interventions:
Followed closely by PMR provider, Natasha Williams, CRNP. Upon admission, she required assistance to complete all mobility and self-care. An individualized therapy program was developed consisting of physical and occupational therapy. She made significant gains. At discharge, she was Min A for transfers and contact guard to ambulate 75 feet with RW. She advanced to Min A upper body bathing and dressing and Mod A for lower body bathing and dressing.
After a successful stay at Providence Rehab, the patient was discharged home with support from family and Penn Medicine at Home. She will continue to be supported by her PCP, Dr. Adam Ellis in the community.
Heart Failure and Cardiac Case Study
55-year-old female admitted to Providence Rehabilitation and Healthcare Center from Lankenau Medical Center, where she initially presented with progressively worsening dyspnea, lower extremity edema and increasing weight. Patient found to be experiencing CHF exacerbation likely in the setting of dietary indiscretion. Patient s/p IV Bumex and then transitioned to oral Torsemide. Past medical history significant for NICM, HFrEF (EF 15%), LBBB s/p ICD, Afib, asthma, OSA, HTN, and HLD. Patient admitted to Providence Rehab for continued medical optimization and continued therapy services.
Nursing Interventions:
Medication Management – Carvedilol, Colchicine, Allopurinol, Jardiance, Spironolactone, Torsemide, sliding scale insulin, Prednisone, Doxycycline
Close Monitoring of Vital Signs including M/W/F weights and Accu-Checks
Close Monitoring of Labs including BMP, C and Magnesium
Maintain Adequate Nutrition – including Heart Healthy Diet with 1500ml fluid restriction
Cardiologist Interventions:
Patient was followed closely by our Cardiologist, Dr. Richard Seifert. While at Providence Rehab, her medication regimen was optimized and at discharge she was
euvolemic on exam.
Pulmonologist Interventions:
Patient was followed closely by our Pulmonologist, Dr. Ajay Pillai and our full-time in-house Respiratory Therapist. While in-house her CPAP settings were adjusted
and she was maintained on Flovent BID and Albuterol HFA PRN.
Therapy Interventions:
Patient made significant gains to regain her independence. At discharge, she was Mod I for self-care and mobility including being able to ambulate 150 feet with RW and safely ascend/descend 15 steps. After a successful stay at Providence Rehab, the patient returned home with support from family and Main Line Health Home Care. She will continue to follow with her Cardiologist, Dr. Christopher Droogan and PCP, Jennifer Gill CRNP in the community.
Urgent SNF Case Study
89-year-old female DIRECTLY admitted to Providence Rehabilitation and Healthcare Center from the community for rehabilitation and nursing care. Patient with ambulatory dysfunction s/p recent fall. She initially presented to the emergency department s/p fall onto her left side with c/o left-sided rib pain. Imaging negative for underlying fracture/dislocation. She was than discharged to a hotel, as she lives alone and was unable to safely navigate the steps in her 2-story home. While at the hotel, she continued to decline, which prompted her PCP Dr. Brooke Salzman from Jefferson Health, to reach out the Providence Rehab directly for admission. PMH: HTN, iron deficiency anemia, CKD III, and trigeminal neuralgia.
Nursing Interventions
Monitoring Vital Signs and Labs – including CMP and CBC w/ diff, Mag, Phos
Maintain Safety – s/p recent fall at home
During her stay at Providence Rehab, she was closely followed by our Nephrologist, Dr. Shazad, who recommended the discontinuation of her Hydrochlorothiazide d/t elevation of her calcium level.
Therapy Interventions
Goals: To be able to safely return home. Patient lives alone in a 2-story house with 4STE and full flight to bed/bath on 2nd floor.
Interventions: Upon admission, patient required Mod A for sit-stand, able to ambulate 15ft with CGA, and unable to ascend/descend stairs. After actively participating with PT/OT, patient progressed to being independent with sit-stand, able to ambulate 300ft Mod I with 2-wheeled walker and safely ascend/descend 15 steps.
After 12 days in STR the patient was able to safely discharge home with support from Continuous Home Health.
Pulmonary / Rehab Care Case Study
85-year-old female admitted to Providence Rehabilitation and Healthcare Center from Mercy Fitzgerald Hospital after she was admitted with sepsis secondary to cellulitis of abdominal pannus s/p antibiotic course. Hospital course complicated by new right lower lobe infiltrate and shortness of breath c/f aspiration pneumonia, started on oxygen 2L via NC. Patient also noted to have dilated main pulmonary artery suggestive of pulmonary hypertension. Past medical history includes HTN, morbid obesity, hypokalemia, hypothyroidism, chronic lower extremity edema, chronic lower leg venous stasis and diabetes. Patient admitted to Providence Rehab for continued PT/OT for ambulatory dysfunction and medical oversight.
Respiratory Interventions
Monitor Vital Signs, Accu – Checks and Weekly Weights
Monitor Cellulitis – monitor for acute changes
Medication Management – Lasix, Hydralazine, Metformin HCl, Synthroid, Meloxicam
Respiratory Interventions
Maintain Adequate Oxygenation
Wean Oxygen as Tolerated – patient weaned to room air during the day
Our Pulmonary Program allowed for in-house Pulmonary oversight by Pulmonologist, Dr. Ajay Pillai. In collaboration with our full time on-site respiratory therapist and the care team, the patient was weaned from requiring oxygen at all times to utilizing 2L oxygen at night for comfort.
Therapy Interventions
Patient’s hospital course was complicated by ambulatory dysfunction and weakness. During her stay, the patient actively participated with PT/OT. Upon admission, she was contact guard assist for all mobility and able to ambulate 20ft with a RW. After a successful stay at Providence Rehab, she was able to advance to a supervision level and ambulate 50ft with RW.
After 18 days at Providence Rehab, the patient was discharged home with support from family and Mercy Home Health. The patient will continue to follow with her PCP, Dr. Nicholas Busillo.
Cardiac Rehab Case Study
73 Year Old Male admitted to Providence Healthcare and Rehabilitation Center after a prolonged stay at Mercy Fitzgerald Hospital with Admitting Diagnosis of S/P CABG x4 with Sternal Wound Dehis cence. Patient wears a Life Vest with a history of Hypertension, I schemic Cardiomyopathy and an EF of 25-30%.
Nursing Interventions
- Administer IV Antibiotics- Vancomycin and Meropenem
- Wound Care- Osteomylitis at the Sternal site
- Maintain Lifevest
- Medication Management- Amioderone, Plavix, Bumex, Coreg
- Monitor Labs- Vanco Levels, BMP, CMP w diff and BNP
Respiratory Interventions
- Maintain Adequate Oxygenation- Oxygen at 2 lpm via nasal cannula
- Pacing and Endurance with Activity
- Smoking Cessation Education
Providence Interdisciplinary Team approach to care allowed this complex patient the ability to be cared for without any unplanned hospital discharges. Our onsite Pulmonologist, Dr. Pilai, and our full-time respiratory therapist-assisted in the care to ensure a smooth continuum.
After a successful Short-Term Rehab stay, the Patient returned home with family. He continues to be followed by Mercy Home Health Services as well as his PCP, Dr. Douglas Keagle and Cardiologist Dr. Marino Leonardi in the community.
Pulmonary Rehab Case Study
56 Year Old Female (V.W) admitted to Provi dence Healthcare and Rehabilitation Center after a 50+ day stay at Mercy Fitzgerald Hospital with Admitting Diagnosis of Ischemic Bowel with History of Hepatitis C and Liver Cirrhosis. Patient Admits to Providence S/P Tracheostomy and Peg tube Placement wi th Abdominal Wound Requiring Wound Vac.
Nursing Interventions
Wound Healing: Abdominal Wound 18x3x2 on Admission requiring Wound Vac
Medication Management: Lasix 40 mg daily, Lisinopril
Maintain Adequate Nutrition: Enteral Feeds on Admission
Monitor Labs: CBC, BMP, BBG’s
Respiratory Interventions
Maintain Patent Airway: Airvo Warm Humidity to assist with managing secretions
Maintain Adequate Oxygenation: Wean as tolerated
Reviewed weekly at Pulmonary Interdisciplinary Team Meeting lead by our in-house Pulmonologist, Dr. Korman. Patient progressed quickly:
Day 6: Trach Weaned
Day 18: Peg Removed-Diet advanced to Regular and Thin Liquid
Day 18: Wound Vac Discontinued
Day 20: Oxygen Discontinued
Upon Discharge: Family Educated on Wound Care to Abdomen
Therapy
Upon Admission, Patient was unable to ambulate and required maximum assist with all self-care. She received Physical and Occupational Therapy 5 times a week for 4 weeks. Upon Discharge, she was independent with all self-care tasks and able to ambulate 40 feet with a roller walker and contact guard.
After 30 days in Short Term Rehab, Patient returned home with husband and supportive daughter. She was followed by Mercy Home Health and will follow with her PCP, Dr. Cynthia Cheng in the community.
Cardiac/Renal Rehab Case Study
IN CENTER BEDSIDE HEMODIALYSIS AND IV MILRINONE
66 year-old male admitted to Providence Rehabilitation Center after an 11 day hospital stay at Mercy Fitzgerald Hospital. He was admitted with Sepsis secondary to Scrotal Abscess. He has a PMH of End Stage Renal Disease, Chronic Systolic Heart Failure and Cardiomyopathy and is not a Candidate for LVAD or Transplantation Surgery.
Nursing Interventions
Monitor Fluid Balance: 1500 ml Fluid Restriction and Daily Weight Monitoring
Wound/Infection Management: Vanco MWF and Care to Scrotal Abscess
Monitor Vitals and Labs: Weights: 184 on admit to 176 on DC and BP managed well.
Medication Management: IV Milrinone at 3ml/hour and Torsemide 40mg BID
Respiratory Interventions
Maintain Adequate Oxygenation: Patient admitted on 2 lpm of oxygen continuous
Therapy
On Admission, the patient could ambulate 30 feet with roller walker and Min A. His Bed mobility were max assist and transfers required Min A.
Upon Discharge, he was ambulating 225 ft with supervision and is climbing 12 steps supervision level.
Bedside dialysis and less travel outside the center, to and from Dialysis, allowed for a less fatigued patient. This resulted in a quicker recovery, a stronger patient and ultimately, a faster return to home.
Patient was weaned off oxygen therapy and returned home on room air. He returned home with his Significant Other after a 17-day LOS in STR. He was discharged with Penn Home Health Services and Discharged back to Davita Waverly in his MWF 1030am time slot. He has follow up appointments secured with his PCP, Dr.Cosa, and is followed by Dr. Ross Zimmer, Cardiology and Dr. Jen Patel, Nephrology.
Pulmonary Rehab Case Study
58 Year-Old male admitted to Providence Healthcare and Rehabilitation Center after a 20 Day stay at Mercy Hospital Philadelphia. Patient was admitted S/P tracheostomy and Peg tube placement secondary to Sepsis Pneumonia with a history of COPD and Hypertension.
Nursing and Respiratory Goals and Intervention
Maintain Safety, Medication Management, Advance PO Diet/ Upgrade consistency
Maintain Patent Airway- Wean airway as tolerated; Bronchodilatation and Secretion Management, Pacing and Endurance with activity and Evaluate Patient for OSA.
Weekly Pulmonary IDT
Care team discussion including Our In-House Pulmonologist as well as our full time Respiratory Therapist.
Accomplishments: Tracheostomy Tube was weaned after successful capping trials while simultaneously working with SLP to advance PO trials over a 12-day coarse of time. Patients
PEG tube was weaned and patient was advanced to a full PO diet consisting of Regular texture and thin liquids. In addition, after successful trach tube weaning, A Sleep Study was conducted at the center to rule out Obstructive Sleep Apnea. Sleep Apnea was ruled out and no nocturnal support treatment was recommended.
Therapy
Upon admission, the patient required moderate assist with bed mobility and transfers. He was not able to ambulate. He participated in Occupational and Physical therapy 6 times a week for three weeks. He discharged to home with his significant other to their apartment with 8 steps to enter. He was independent in all self-care tasks and able to ambulate 100′ with a Single Point Cane with Supervision and is ambulating 15 stairs.
He returned home after a 24 day stay in STR with VNA services from Mercy Home Health. He was followed by our in-house Pulmonologist, Dr. Korman, throughout his stay in Short term rehab. Upon Discharge, he will follow up with his PCP Dr. Gathers and Dr. Michael Sherman, Pulmonologist at Drexel Med.
Cardiopulmonary Rehab Case Study
76 year-old female admitted to Providence Rehabilitation Center after a 20 day hospital stay at Penn Medicine. She was admitted with Chronic Diastolic CHF, Pulmonary Hypertension and COPD. In the hospital, she originally required Optiflow High Flow O2. She was successfully weaned to 8-10 liter via nasal cannula- making Next Level Short Term Rehab Placement a bit challenging. Our Specialty Level Physicians as well as Complex Care Team made Providence the right place for her!
Nursing Interventions
Monitor Fluid Balance: 1500ml Fluid Restriction
Daily Weight Monitoring, Lasix 80mg BID with Potassium supplementation;
Dietician educated on Heart Healthy Food choices.
Monitor Vitals and Labs: Vitals monitored Q Shift and weekly CBC and BMP
Medication Management: Continue Tadalafil for Pulmonary Hypertension
Respiratory Therapy Interventions
Maintain Adequate Oxygenation: Admitted on 8-10 lpm via Nasal Cannula;
Converted to conserving device to allow optimal oxygenation and improvement
Bronchodiliation, Pacing and Endurance Training with Activity
Weekly Cardiac IDT
Care team discussion including Our In-House Nurse Practitioner as well as our In-House Pulmonologist and Respiratory Therapist.
Therapy
On Admission, Maggie could ambulate 20 ft with roller walker and Min A with increased work of breathing and fatigue. Her Bed mobility and transfers also required Min A. She climbed 2 steps with CGA. Upon Discharge, Maggie was ambulating 125 ft with a roller walker and distant supervision for both ambulation as well as bed mobility; She was climbing 15 steps with supervision.
Patient returned home with her daughter and granddaughter after a 13 day LOS in STR. She was seen by Cardiologist in the community and was seen by our in house Pulmonologist, Dr. Korman, IN THE CENTER PRIOR TO DISCHARGE.
