Test Your Knowledge
What differential diagnosis would you make after Betty's primary care provider visit and exam?
Medication Review with Pharmacist
Betty’s primary care provider has prescribed Naproxen to assist Betty in her pain management. The pharmacist is able to come and counsel Betty on Naproxen. The following is the session with Betty and the pharmacist.
Naproxen Risk
What is the potential risk of using naproxen in a 78 year-old woman like Betty?
General risk of NSAIDs are dependent on underlying patient conditions, dose of NSAID used, and length of the treatment. The primary mechanism tied to NSAID toxicity is related to their mechanism of action which is inhibition of prostaglandin synthesis.
Cardiovascular
Variety of effects including potential for myocardial infarction, strike, or
heart failure especially in those with pre-existing disease.
Hepatic
Elevations in serum transaminases.
Hematologic
NSAIDs can cause inhibition of platelets placing people at higher risk of bleed; combination with other anticoagulants or antiplatelet may increase the risk.
Gastrointestinal
May cause dyspepsia, peptic ulcer disease, and risk for GI bleed.
Renal
May cause acute kidney due to vasoconstriction, electrolyte and fluid abnormalities such as hyperkalemia, hyponatremia, and edema; potential worsening of hypertension.
Central Nervous System (CNS)
May be associated with cognitive impairment in older patients, psychosis, and tinnitus.
Follow-Up Care Order
Which services would be the best for Betty for follow-up care – outpatient physical therapy or home health services?
Guidelines for Home Care Eligibility
Home Care Eligibility – Medicare
- Medicare Eligibility: Part A and /or Part B
- Patient needs to be under the care of a doctor
- You must need one or more of the following:
- Intermittent skilled nursing care
- Physical therapy, speech-language pathology or occupational therapy services which requires skilled services of a qualified therapist.
- Must be homebound and doctor certifies you are homebound
- You may leave home for medical treatment or short, infrequently absences for nonmedical reasons
Source
https://www.medicare.gov/coverage/home-health-services.html
Outpatient Services
- Medicare Part B (Medical Insurance) 20% copay for services
- Nursing outpatient services are not a covered Medicare service
- Social Services outpatient services are covered when they are provided by a health care provider who accepts assignment.
- Physical Therapy: Medicare helps pay for medically necessary outpatient physical therapy, speech-language pathology or occupational therapy. There are limits on these services. The therapy cap limits for 2017 are:
- $1,980 for physical therapy (PT) and speech-language pathology (SLP) services combined
- $1,980 for occupational therapy (OT) services
Source
https://www.medicare.gov/coverage/outpatient-mental-health-care.html
https://www.medicare.gov/coverage/speech-language-pathology-services
Primary Care Provider: Additional Orders
After Betty’s visit, the primary care provider has ordered:
- Medication: Naproxen. A proton pump inhibitor was not added as the timeframe for the Naproxen is expected to be limited.
- Home Health Services for Nursing, Social Services and Physical Therapy
- Follow-up visit with primary care provider.
Test Your Knowledge
Question 1
Which additional orders you feel would be appropriate for Betty at this time?
Question 2
When should you schedule a follow-up visit for Betty with her primary care provider?
Discussion
Imaging is not recommended at this time based on the differential diagnosis. Four weeks is the most correct answer in order to see a significant difference in benefit from the anti-inflammatory and additional services ordered.
