Care Transitions for a Patient with Multimorbidity After Hospitalization
Mrs. K is an 80-year-old woman with type 2 diabetes, hypertension, heart failure (EF 40%), and mild cognitive impairment. She was hospitalized for 5 days with a COPD exacerbation and was discharged home yesterday. Her discharge medications include: prednisone 40 mg daily for 5 days, levofloxacin 500 mg daily for 7 days, and her home medications: metformin 1000 mg twice daily, lisinopril 10 mg daily, carvedilol 3.125 mg twice daily, furosemide 20 mg daily, and albuterol inhaler as needed. She lives alone and has a daughter who checks on her weekly. She is confused about her medications and missed her evening doses yesterday. Her blood glucose readings have been 180–250 mg/dL. She has a follow-up appointment with her primary care provider in 2 weeks.
1. What are the key risk factors for readmission in this patient, and what transitional care interventions would you prioritize?
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Risk factors:
- Polypharmacy and regimen complexity: New medications (prednisone, levofloxacin) added to an already complex regimen, increasing risk of confusion and nonadherence.
- Cognitive impairment: MCI affects her ability to manage medications and recognize symptoms.
- Lives alone: Limited daily support; daughter only weekly.
- Recent hospitalization: COPD exacerbation indicates severe disease and risk for recurrence.
- Multiple chronic conditions: Diabetes, HF, hypertension increase risk of decompensation.
- Medication interactions: Prednisone can worsen hyperglycemia and fluid retention; levofloxacin can cause dysglycemia and QT prolongation.
Prioritized interventions:
- Medication reconciliation and simplification: Use a pill organizer, provide a written schedule with times, and involve daughter in setup. Consider blister packs.
- Patient education: Teach-back on medications, warning signs, and when to call. Use large print and simple language.
- Follow-up: Schedule a phone call within 48–72 hours and an earlier clinic visit (within 1 week). Consider home health nursing.
- Coordination: Send discharge summary to PCP; ensure home health aide for medication management.
- Monitoring: Check blood glucose logs; adjust diabetes medications as needed (prednisone may require insulin temporarily).
2. How would you address her hyperglycemia in the context of her new prednisone and levofloxacin?
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Assessment: Prednisone causes insulin resistance and increases hepatic glucose production; levofloxacin can cause dysglycemia (both hypo- and hyperglycemia). Her current metformin may be insufficient.
Plan:
- Monitor: Check blood glucose before meals and at bedtime; keep a log.
- Adjust medications: Consider adding a basal insulin (e.g., glargine 10 units daily) or a prandial insulin if glucose remains >250 mg/dL. Avoid sulfonylureas due to hypoglycemia risk. If adding insulin, educate on injection technique and hypoglycemia recognition.
- Taper prednisone: Ensure prednisone is tapered after 5 days to avoid rebound inflammation and hyperglycemia.
- Hydration: Encourage water intake to prevent dehydration.
- Follow-up: Recheck HbA1c and adjust diabetes regimen after acute illness resolves. Coordinate with diabetes educator.
- Safety: Review hypoglycemia symptoms and treatment; ensure she has glucose tablets at home.