Interprofessional Healthcare Team Meeting (IPE)

Summary

The video features Ral Kar, medical director of a clinic, discussing the interprofessional collaborative approach for treating patients with multiple chronic diseases. The clinic's transdisciplinary team, including medical professionals, social workers, and health promoters, focuses on holistic care, addressing medical, educational, and socioeconomic barriers. The team discusses a patient's care plan, highlighting their collaborative efforts to navigate complex healthcare needs and connect patients to community resources.

Takeaways

• 🏥 The clinic specializes in caring for unfunded patients with multiple chronic diseases who frequently use hospital or emergency services.
• 👥 Care is provided through a transdisciplinary team model that includes a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist.
• 🤝 The team operates with a flattened hierarchy, emphasizing collaboration and equal input from all members, regardless of their professional role.
• 📋 The team's approach is patient-centered, focusing on education, health literacy, and addressing socioeconomic barriers to care.
• 🏠 The team conducts home visits, which are crucial for understanding patients' lifestyles and providing personalized care.
• 📝 The clinical pharmacist plays a vital role in consulting on medication management across all teams.
• 👩‍⚕️ The advanced practice registered nurse provides comprehensive care, including physical exams, diagnostics interpretation, and patient education.
• 👩‍💼 The medical social worker addresses biosocial concerns and barriers, such as family dynamics, finances, and mental health, that impact patients' health.
• 🌟 The health promoter or community health worker establishes trust with patients and serves as a liaison between health services and the community.
• 🍽️ The dietitian, with a focus on diabetes education, works with patients to understand their dietary needs and lifestyle, often conducting home visits for better rapport.
• 📆 The team coordinates care by reconciling medication lists, managing appointments, and ensuring patients have access to necessary resources like Meals on Wheels.

Q & A

What is the primary focus of the clinic described in the script?

The clinic focuses on the care of unfunded patients with multiple chronic diseases who are high utilizers of hospital or Emergency Department Services.

How does the health care delivery model differ in this clinic from traditional settings?

In this clinic, care is delivered through a transdisciplinary team model that removes hierarchy, emphasizing collaboration and equal importance of all team members' voices.

What roles do the team members play in the patient's care plan?

Team members include a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist, each contributing unique skills to address medical, educational, socioeconomic, and community resource needs of the patients.

What is the significance of the patient-centered approach mentioned in the script?

The patient-centered approach involves the patient as part of the care team, considering their unique needs and circumstances to formulate realistic care plans and improve outcomes.

How does the advanced practice registered nurse contribute to the team?

The advanced practice registered nurse provides comprehensive care, including physical examination, diagnostics interpretation, prescribing, patient education, care coordination, and communication with other providers.

What specific challenges does Mr. John Smith face as described in the case conference?

Mr. John Smith faces challenges such as an upcoming change in housing, safety concerns due to leaving the stove on, psychiatric symptoms possibly indicating medication issues, and visual hallucinations leading to an emergency department visit.

What is the role of the medical social worker in addressing Mr. Smith's situation?

The medical social worker assists Mr. Smith in addressing biosocial concerns and barriers, such as family relationships, finances, housing, transportation, and mental health, which may hinder his health.

How does the health promoter or community health worker contribute to Mr. Smith's care?

The health promoter establishes trusting relationships with patients, serves as a liaison between health and social services, facilitates access to services, and improves the quality and cultural competence of service delivery.

What is the significance of the dietitian's role in the team, particularly for Mr. Smith?

The dietitian provides specialized care for patients with conditions like diabetes, hypertension, and other dietary needs, offering home visits for a better understanding of the patient's lifestyle and to tailor care accordingly.

What steps are being taken to address Mr. Smith's immediate needs and future sustainability?

The team is planning to increase their involvement with Mr. Smith by providing wraparound care, connecting him with resources like Meals on Wheels, assisting with medication management, and exploring housing opportunities to ensure his immediate needs are met and a more sustainable long-term plan is in place.

Outlines

00:00

🏥 Introduction to the Interprofessional Healthcare Team

Ral Kar, the medical director, introduces the clinic's focus on caring for unfunded patients with multiple chronic diseases who frequently use hospital services. The clinic operates through a transdisciplinary team model, which includes a provider, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist. The team aims to provide comprehensive care, emphasizing education, health literacy, and addressing socioeconomic barriers. They also strive to connect patients with community resources and specialty care. The video will showcase the team's collaborative process in creating a patient's care plan, highlighting the unique, flattened hierarchy that values every team member's input equally.

05:02

📝 Roles and Experiences in the Healthcare Team

The team members discuss their roles and experiences. The physician explains the collaborative nature of the team, where no single voice dominates, allowing for a more rewarding practice. The advanced practice registered nurse uses a holistic approach to manage patient conditions, considering psychological, financial, and social factors. The clinical nurse navigator serves as the team lead, facilitating meetings and developing care plans. The medical social worker addresses biosocial concerns and barriers to health, such as family dynamics and housing. The health promoter, or community health worker, establishes trust with patients to improve service delivery and cultural competence. The dietitian, who works with multiple teams, focuses on lifestyle and provides home visits for a better understanding of patients' needs.

10:04

🏠 Case Discussion: Mr. John Smith's Changing Circumstances

The team discusses the case of Mr. John Smith, who is facing housing instability and health concerns. He is moving in with family due to the closure of his current residence, but he has a history of anxiety and past verbal abuse from a family member. The team is increasing its support to ensure his care continues, with plans to address his housing situation, medication management, and coordination with specialists. They also discuss his recent emergency room visit due to visual hallucinations and concerns about his medication regimen, which may be causing side effects. The team is working to reconcile his medication list and communicate effectively with all his healthcare providers.

15:07

💊 Medication Management and Memory Concerns for Mr. Smith

The discussion continues with Mr. Smith's memory issues and the complexity of his medication management. The team is concerned about potential side effects from his medications and the need for accurate, up-to-date medication lists. They plan to reinforce medication management during home visits and consider options for outpatient programs to support his mental health. The team also addresses his recent cognitive test results, which showed no significant cognitive decline, and the implications for his insurance coverage and potential need for neurologic testing.

20:08

🏡 Addressing Mr. Smith's Immediate Needs and Long-Term Care

The team concludes the discussion by focusing on Mr. Smith's immediate needs, such as ensuring he has access to food and managing his gastroparesis through Meals on Wheels. They also plan to reinforce his calendar with upcoming appointments and create a shared document to keep track of his healthcare journey. The team aims to provide comprehensive support, including evaluating his recent ER and psychiatry visits, to consolidate his care and address any issues that may be contributing to his symptoms.

Keywords

💡Interprofessional Collaborative Competencies

Interprofessional collaborative competencies refer to the skills and attributes that enable professionals from different disciplines to work together effectively. In the video, this concept is central as the clinic's team, which includes a physician, nurse, social worker, and other healthcare providers, collaborates to create comprehensive care plans for patients with multiple chronic diseases. The script illustrates how each team member contributes unique skills to address the patients' medical, social, and educational needs.

💡Transdisciplinary Team

A transdisciplinary team is a collaborative group of professionals from various disciplines who work together to solve complex problems, integrating their knowledge and expertise. In the video, the clinic's approach to patient care exemplifies a transdisciplinary team model, where a provider, nurse navigator, social worker, health promoter, and dietician all contribute to a patient's care plan, ensuring a holistic approach that addresses medical, social, and educational barriers.

💡Healthcare Navigation

Healthcare navigation involves assisting patients in accessing and navigating the complex healthcare system. The script mentions a 'nurse Navigator' who plays a crucial role in guiding patients through the healthcare system, which can be particularly challenging for those with chronic diseases. This includes coordinating care, facilitating communication between different healthcare providers, and ensuring patients receive the necessary services.

💡Health Literacy

Health literacy is the ability of individuals to access, understand, and use information to make informed decisions about their health. The video emphasizes the importance of health literacy in patient care, as the team not only provides medical care but also focuses on educating patients to improve their understanding of their health conditions and treatment options, which is vital for self-management and adherence to care plans.

💡Socioeconomic Barriers

Socioeconomic barriers refer to the social and economic factors that can hinder an individual's access to healthcare services. In the script, the clinic's team addresses these barriers by connecting patients to community resources and sub-specialty care, which can include financial assistance, housing, and transportation services. By doing so, the team aims to reduce the impact of these barriers on patients' health outcomes.

💡Chronic Diseases

Chronic diseases are long-term health conditions that require ongoing management and care. The video discusses the clinic's focus on patients with multiple chronic diseases, who often face challenges in managing their conditions due to the complexity of their healthcare needs. The team's comprehensive approach to care planning is designed to address the unique challenges faced by these patients.

💡Care Coordination

Care coordination is the organization and management of healthcare services to ensure that patients receive the right care at the right time. The script illustrates care coordination through the team's efforts to create and implement a patient's care plan, which involves coordinating services from various healthcare providers and ensuring that the patient's needs are met across different care settings.

💡Community Health Worker

A community health worker is a frontline public health worker who serves as a liaison between health and social services and the community. In the video, the role of the health promoter or community health worker is highlighted, emphasizing their importance in establishing trust with patients and facilitating access to services. They also help patients incorporate their care plans into their lives, considering social and cultural contexts.

💡Clinical Pharmacist

A clinical pharmacist is a healthcare professional who specializes in providing pharmaceutical care to patients. In the script, the clinical pharmacist's role is mentioned as they consult with the team on all patients' medication regimens, ensuring the safe and effective use of medications. This is crucial in managing patients with multiple chronic diseases who may be on complex medication regimens.

💡Patient-Centered Care

Patient-centered care is an approach to healthcare that prioritizes the patient's values, needs, and preferences in healthcare decision-making. The video script describes how the team utilizes a patient-centered approach, considering the patient as a part of the team and involving them in the development of their care plan. This approach aims to improve patient outcomes by ensuring that care is tailored to the individual's unique circumstances.

💡Holistic Approach

A holistic approach in healthcare considers the whole person, including physical, emotional, social, and spiritual aspects, when providing care. The script mentions that the advanced practice registered nurse uses a holistic approach to evaluate and manage patient conditions, taking into account not only the medical conditions but also psychological, financial, social, and family circumstances to formulate a realistic care plan.

Highlights

Clinic focuses on care for unfunded patients with multiple chronic diseases and high utilization of hospital services.

Healthcare delivery is through a transdisciplinary team model that includes a variety of healthcare professionals.

Team members include physician, nurse navigator, social worker, health promoter, dietician, and clinical pharmacist.

Emphasis on medical care, education, health literacy, and addressing socioeconomic barriers.

Team seeks to connect patients to community resources and sub-specialty care.

Physician role in the team setting is collaborative, with no hierarchy.

Advanced practice nurse provides holistic care, including home and phone visits.

Clinical nurse navigator facilitates team meetings and develops interdisciplinary care plans.

Medical social worker assists with biosocial concerns and barriers to health.

Health promoter acts as a liaison between health services and the community, addressing social and cultural contexts.

Registered dietitian provides nutritional care and education, with a focus on diabetes management.

Team discusses Mr. John Smith's care plan, addressing recent changes and challenges.

Mr. Smith is moving to a new living situation, which presents both risks and support opportunities.

Team plans to increase involvement to provide wraparound care for Mr. Smith.

Concerns about Mr. Smith's medication management and potential side effects are discussed.

The team considers Mr. Smith's mental health, including recent hallucinations and memory issues.

Coordination of care and communication among specialists is emphasized to ensure Mr. Smith's needs are met.

The importance of patient education, particularly regarding diabetes management, is highlighted.

Team members collaborate on housing solutions and ensuring Mr. Smith's safety and well-being.

The team discusses the potential for Mr. Smith to participate in a diabetes education class for potential benefits.

Coordination of Mr. Smith's medication list and calendar is part of the ongoing care plan.

The team considers Mr. Smith's dietary needs and the possibility of connecting him with Meals on Wheels.

The importance of reinforcing Mr. Smith's understanding of his condition and treatment is discussed.

The team plans to evaluate Mr. Smith's recent ER visit and psychiatric care to consolidate his treatment plan.

Transcripts

I'm Ral Kar medical director for a

clinic that oversees the care of

patients with multiple chronic diseases

the purpose of this video is to

demonstrate the interprofessional

collaborative

competencies by visualizing an actual

transdisciplinary

team in the process of creating a

patient's care plan our Clinic focuses

on the care of unfunded patients with

multiple chronic diseases who are high

utilizers of the hospital or Emergency

Department Services these

patients often have difficulty

navigating through the Health Care

system which can be quite complex and

also face multiple barriers seeking and

obtaining care care is delivered through

a transdisciplinary team model our team

consists of a provider either a

physician a nurse practitioner or a

physician assistant a nurse Navigator a

social worker and a health promoter or

also known as a community health worker

we also have a dietician who

participates on the team there is a

clinical pharmacist available in the

clinic who consults on all the teams as

well together the team provides not only

medical care but also provides a heavy

emphasis on education health literacy

and addressing socioeconomic barriers to

obtaining care we also seek to connect

patients to various resources in the

community and sub specialty care you're

going to meet the members of a care team

hear about their roles experiences

working on a team and observe a typical

case conference where they are

discussing a patients care

plan I'm a general internist by training

at what is unique to The Physician role

in this team setting versus a more

traditional uh hospital setting or

clinic setting is that the hierarchy is

removed and so my voice in an

interprofessional team is no more

important than any other person's voice

at the table um which is very rewarding

and a gratifying way to practice because

you gain a lot from your other team

members and you're really able to lean

on them for things that we can't

completely handle as Physicians

ourselves as the advanced practice

registered nurse on our team for uh I

care for our patients in the clinic and

in the home setting and also by phone

when necessary during these visits I use

a holistic approach to evaluate and

manage new and ongoing patient

conditions I provide comprehens a

comprehensive perspective to our

patients Healthcare needs um this means

that in addition to considering the

patient's medical conditions I also eval

evaluate psychological Financial social

family circum and family circumstances

in order to formulate a realistic care

plan physical examination interpretation

of Diagnostics prescribing patient

education care coordination and

communication with other providers are

some of the specific tasks I perform

daily I also act as a team resource to

troubleshoot complex

issues in regards to working with a team

we utilize a patient- centered approach

to care and consider our patient to be

part of our team as a team we all

contribute un unique skills knowledge

and qualities that allow us to identify

strategies that can lead to improved

outcomes for our patients we communicate

with each other frequently both in

formal meetings and informally by email

and phone calls at our formal case

conferences we review our patient cases

and discuss the care plan and patient

needs as a clinical nurse Navigator I

serve as the team lead including

facilitating the weekly team meetings

additionally I help to develop revise

and communicate interdisciplinary care

plans with the team my role in patient

care involves a combination of home

visits office visits and telephone

conversations with the patient for the

purpose of education assessment and care

coordination my nursing background

includes just over 3 years of intensive

care experience and a Bachelor's of

Science and nursing as a medical social

worker on a transdisciplinary team my

role is to assist patients in addressing

biosocial concerns and barriers that may

hinder them from being as healthy as

they can or hinder them from focusing on

their healthare needs these barriers

often include family relationships

finances housing transportation and

mental health concerns my interactions

with patients include bios

biopsychosocial assessment

individualized treatment planning care

coordination discussion of referral to

federal state county and City

programs and

education within the hospital system for

which I work um I've worked for almost 5

years all medical social workers must

have earned a master of Social Work

degree prior to hire and hold a licensed

master a social work licensure or

licensed clinical social work licensure

as a health promoter Community Health

worker I'm a Frontline Public Health

worker whom establishes trusting

relationships with patients to better

serve as a liaison link intermediary

between Health and Social Services and

the community to facilitate access to

services and improve the quality and

cultural competence of Service delivery

I'm also certified as a clinical nurse

assistant having worked in an orthot

trauma unit for 7 years for certifying

as a health promoter and Community

Health worker uh in this

interprofessional team um I help

patients understand and incorporate

their care plan into their lives

considering social and cultural context

um I also help identify barriers to the

team that they were unaware of um in my

list of Duties I reinforce education

taught to patients with chronic

illnesses uh assist patient with

preparation for important appointments

visit patient in hospital Andor Patients

Preferred locations such as home visits

or clinical uh appointments help locate

patients whom have become inactive or

are homeless uh accompany patients to uh

Primary Care specialty and other Health

Community Resource appointments uh coach

patients in order to promote self-care

Independence patient advocacy resource

allocation liaison for patient between

medical community and Community

Resources help identify safety hazards

in patients dwelling and help manage

patient source of transportation and or

communication I am a registered

dietitian I have a bachelor's degree in

nutrition and I have been a certified

diabetic educator for 11 years and have

worked in the outpatient setting for the

past 16 years my role as dietitian

within the team is slightly different

than the other team members and that the

dietician is not specifically designated

to one team but instead is designated to

three or four different teams I try to

schedule as many of my appointments as

home visits because I find that I have a

better chance to obtain an ACC accurate

picture of the patient's

lifestyle and also that I tend to have

much better rapport with the patient

when I have home visits um the majority

of the patients I see are for

diabetes but in addition to that I also

have referrals for hypertension

congestive heart failure high

cholesterol celiac disease as well as uh

periodic interal tube feeding I rely on

communication from my team members for

accurate information as to why I've

received the referral as well as what

the patient is wanting out of the

referral I look to my designated

advanced practice nurse when I am

confronted with a medical condition

outside of my scope of care and for

example a patient with a very high blood

sugar during the visit I also

periodically make referrals to my other

team members when a patient need arises

that is also outside of my scope of care

um for example if a patient needs to be

accompanied to a specialty

appointment okay so in our meeting today

I think we're going to talk about uh Mr

John Smith who has had some recent

changes so Megan do you want to speak a

little bit more about the changes sure

um so as El mentioned we we visited

yesterday to his residence at front

steps um we learned actually when we got

there that he is going to be leaving as

of tomorrow and this was brand new

information to him yesterday as well so

um we this has been sort of I think a

little bit cing um he's living with a

few other residents and most of them are

pretty independent and it seems as

though Mr Smith has been being watched

out for by these roommates which is very

sweet but it's not their responsibility

it's not part of what they're supposed

to be there they're supposed to be there

for their own

Services um but it seems as though

separately that they're closing the

house so the last of the roommates

actually moves out tomorrow as well so

that we know one

there and in addition to that it he's

been leaving the stove on so it's been

he's he's unsafe by himself and he has

also it seems as though his psychiatric

symptoms have been presenting themselves

um maybe his medications aren't working

at this point maybe he's um so that

that's something that has recently been

visited but he most recently uh seemed

to be having some visual hallucinations

and saw something on the wall that was

very upsetting to him so it actually

resulted in him going to the emergency

department um and so besting this has

all been coming coming to a head so Leah

the I think most of you know her she

runs The recuperative CARE program

through front

steps um so she had a conversation with

me yesterday we happened to be there and

the plan is for him to move in with his

mom and stepdad I think we've spoken

before he has some anxiety around his

stepdad uh he used to live with them

there's uh dad uses alcohol stepdad us

alcohol and there's been some verbal

abuse in the past so he he's got some he

was pretty anxious about it but

recognizes that it's the only other

option right now so where I see us

coming in is to really step up our

involvement with him provide some

wraparound care and try to to fill in

where he's been so dependent on Leah and

front steps for so long that we really

need to step up our involvement and make

sure that he gets the care he needs

until he gets well continuing on past

the time that he gets more housing

different housing

situation and I can help to um find some

programs to help get him out of the

house I know that's going to be a focus

for him going forward um at least in the

interim with hopefully this is just a

temporary situation and we can find him

something more sustainable long term um

I can help with that and and one thing

that I did hear recently that I think

would be a perfect fit for him is

there's a diabetes education class um it

sounds like it's um it's on Tuesdays I

think once a week for a couple hours and

if he goes to seven out of the eight

classes he gets a a grocery store gift

card for about $200 so I think that

would be right up his alley in several

ways so um I think Kristen I think

you're connected with the dietitian that

runs that program right I know the

dietician that facilitates that so I can

get him in touch with her okay yeah that

would be great okay I think that would

be a good place to to start so and

relating to his housing I will be seeing

him tomorrow because his um funding is

about to expire his map card so as I'm

there while we're waiting for his

appointment to start we can start

calling around and seeing if there's any

housing opportunities for him since we

know his current situation has to be

temporary since he's not comfortable

being at home

so um well Megan you had mentioned um

the hallucinations and some um memory

and mental health issues and I know I

know he's on many meds for many chronic

conditions and I'm kind of concerned

that you know these meds may be causing

some issues for him and and it sounds

like we may not even know exactly if

he's on all of those medications and

he's got several Specialists so they may

not even have the most upto-date

medication list so um I'll work to uh

reconcile his medication list and then

chenia maybe we can uh coordinate so

that um we can communicate the most

accurate medication list to all of his

specialists and his primary care doctor

that sounds great idea yeah I mean

usually since I accompany him to these

appointments to make sure that if there

are any changes I also assist him uh

communicating that to all of his

providers is he being stable with his

primary care provider

um yes but um you know just

Transportation has been an issue you

know getting him to his appointments um

he always complains about foot paint um

he doesn't have the best diabetic shoe

so I'm going to try to help him

coordinate that but um if he loses front

steps they are the ones that also

assisted him with getting into his

appointments so that's that's going to

be another issue that we're going to

have to kind of figure out but he he he

does try to make it to his appointments

they never have the um updated med list

so that's been an issue so really

communicating to the providers is going

to be the key here that's something an

and I can work on together reaching out

to them that actually couple those

points um we he did earlier last week I

accompanied him to an appointment with

his psychiatrist atcc

and so hopefully we're we can address

those um the psychiatric concerns that

seem to be presenting themselves right

now they did what sort of brought it on

was of course the emergency room visit

but also of course um his ixa yeah has

it increases blood sugar as one of a

side effects so they've decided to put

him back on HD he's not it for a few

days now um but he does have a history

of tarto discinesia um as result of that

he's had some hand tremors so he's a

little bit concerned about that but um

the psychiatrist and and Mr Smith

decided that they were they would try

that at this point um

also he had regarding the memory that

you had addressed he the psychiatrist

did do a cognitive test on him the mini

mental status exam and he actually did

pretty well on it on a scale of 30 he

got a 25 which is wonderful because it's

demonstrating that he's not you know

having some cognition issues of course

but I think demonstrating it in to day

living yeah we had discussed that

there's that memory the gaps in there

that short-term memory is really

troubling from our perspective

so um we were hoping that if he scored

low enough on this exam that that would

suggest that he would be eligible for

disability and then he could with that

Associated funding source of Medicare or

Medicaid depending on his work history

that you would be able to go ahead and

get some neuros testing um but you can't

get the neuros testing unless you have

um a funding source such as Medicaid or

M Medicare and map won't pay for it so

so it's kind of um hoay for having a a

high level high score on your cognition

test but also what's going on with his

memory and and getting him some good um

long-term insurance coverage so so just

want to update you guys on that and

regarding the memory issues as well as

you guys know I had been doing uh weekly

home visits with him to um help fill his

pill box and make sure his medications

are refilled and that kind of thing um

so we can try to move those um to the

hospital I guess uh if he's open to that

I think he will be to get out of the

house um so when I do those it's it's

obviously really helpful for me that you

have those medication lists and then if

you guys could help to reconcile the

medication list so that I'll know um

what needs to go in his pill box um and

I'll help him with that we'll also try

to make as many of the calls as we can

during those visits um but sometimes I

know there's still some followup that he

needs to do afterwards to get some

medications so for the most part you

know I because he does like his

independence as much as he can have it

so I I will occasionally send him a

reminder to just call the pharmacy and

do the the refill so it helps him it

helps him to

be he and also he completed his um SE

and behavior health IOP program with

Julie and Julie had recommended that he

now that he's completed that that he

continue um with an outpatient program

where he can actually work and get a

meal um he can be there a couple days a

week um and he's also expressed some

interest in doing some alanon classes to

deal with the stress of being at home

with his dad and the potential alcohol

abuse that could continue to happen

there so there'll be other ways for him

to get out of the house it sounds like

he's expressed interest so he has he

actually mentioned an Austin Clubhouse

which I was going to try to get

information for so when I do see him

tomorrow it is a um map renewal

appointment I was going to kind of help

him do some research and provide

whatever I can find so and if you have

any ideas let me know M we'll do so

having him see you and I think we should

continue to help him brainstorm some

options help him get out of the house

sounds good I'll definitely do that on

my weekly visits and and additionally

obviously the pill boxes and um you know

assessing him for the various concerns

that we have um we know he has the the

memory issues and other clinical things

going on so I can help keep an eye on

those and and check vitals and things

like that as well as well um and

speaking of those weekly visits I wanted

to mention to you Kristen the last um

home visit that we had with him he

mentioned that he was having a low blood

sugar uh whenever he was getting off the

bus one day and so he um went to the

convenience store to buy a Diet Coke and

drink that um in hopes of reming his low

blood sugar so um between you and I

maybe we can both give him some

education on um on diabetes and um

hypoglycemia have sugar in it so you

have your pill box fill on which on

Tuesdays I try to do them usually on

Tuesdays okay so how about if I go see

them on every Thursday sure so we

reinforce that the appropriate treatment

for with the memory concerns I think

that's probably going to be our our plan

is to just continue to reinforce things

with them oh and uh he mentioned to me

that he's concerned with his living with

his mother that his stepfather is not

really giving him access to the food in

the house and also I've heard that the

food in general there is very high high

in fat which is really bad for his

gastroparesis and limited stomach

motility so I was thinking I'm going to

connect him with uh Meals on Wheels they

actually have a low fiber um PID option

for people with gastro press oh that's

great I didn't know that yeah so he'll

get a hot meal every day of the week he

does have snap as well so hopefully

supplement that as well okay that'll

help those two working together will

hopefully address those concerns and

another thing you and I could work

together on um usually when he comes in

for his weekly or when I see him at home

or now it's probably going to be in the

hospital um his weekly visit um we

reconcile his calendar I know he has a

lot of Specialists and appointments and

things like that um so that's one thing

maybe you and I can both work on is

reinforcing that calendar and just

making sure that it's updated with every

appointment you go to that the follow-up

appointment is listed on his calendar

and I'll help to reinforce that and and

get that reconciled every time I see him

weekly maybe we can create a Word

document that we can all see so whoever

sees him can take a recent copy of

allice appointment absolutely right and

I know he keeps his own calendar as well

so just making sure that that document

is updated with his calendar sounds good

the one last thing I would like to bring

him up to the office and just evaluate

um his recent ER visit his recent

Psychiatry visit and sort of consolidate

everything make sure that there's

nothing that we're doing that's making

him worse or causing the hallucinations

he's got definitely got poly Pharmacy as

an issue um and in addition to that he's

medically complex has mult comorbidities

which could be causing um there could be

metabolic things causing his

hallucination so we definitely want to

rule those things out okay yeah and I'll

make sure that my next visit with him

for pill box and assessment and

everything actually happens at the

hospital I think he'll be fine with that

and then that way we can send him to the

lab while he's here great thanks a lot

but then with then if he comes in a week

and a half or something we should be

able to he should be able to tell you

how he's feeling about his symptoms if

if it is in fact psychiatric as opposed

to something else great great okay

thanks all right thanks

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