The 'Noncompliant' Heart Failure Patient
Mrs. R is 74 and lives alone on the second floor of a walk-up. She has heart failure with reduced ejection fraction (EF 30%) and has been hospitalized three times in five months, twice for volume overload. Her primary care physician refers her for case management with a note reading only "noncompliant with medications." At intake she says she takes "the water pill when my ankles swell," keeps her pills loose in a shoebox, and has missed her last two cardiology appointments because the trip requires two bus transfers. She scores 12 on the PHQ-9. She has Medicare and full Medicaid. Her only daughter lives 90 minutes away and calls weekly.
1. How will you determine the level and intensity of case management Mrs. R receives? Name the specific factors you would weigh and describe your engagement plan for the first 30 days.
Read the worked answer
Do not let the referral wording set the plan. "Noncompliant" is a conclusion, not an assessment; it also frames the problem as a character flaw rather than a set of modifiable barriers.
Factors that drive intensity:
- Prior utilization - three admissions in five months is the single strongest predictor of another one, and readmissions cluster in the first 30 days.
- Social determinants - living alone, second-floor walk-up, two-transfer transport, dual-eligible status.
- Clinical complexity - HFrEF plus polypharmacy (assume 8–12 meds until reconciled).
- Behavioral health - PHQ-9 of 12 is moderate depression, which independently predicts nonadherence and readmission.
- Knowledge/health literacy - the shoebox and the as-needed diuretic show a gap in the why, not just the what.
Plan: intensive, face-to-face case management with contact within 2 business days of referral and at least weekly contact through day 30, tapering only when the plan is stable. Structure the 30 days around a written self-management plan, a scheduled 7-day post-discharge/provider follow-up, and explicit reassessment points at 14 and 30 days.
Reasoning: intensity should be matched to modifiable risk and time-to-next-event, not to payer category or diagnosis alone.
2. You have limited time this week. Which three interventions do you make first, and why in that order?
Read the worked answer
1. Medication reconciliation and a workable regimen. Contact the cardiologist and pharmacy, build a pill organizer with a clearly labeled daily schedule, and test understanding with teach-back. Ask directly about cost - Medicaid may cover the meds while a $4 copay on a fixed income can still derail adherence. Simplification (once-daily formulations, 90-day fills, mail order) beats exhortation.
2. Symptom self-monitoring with a written action plan. Daily weights at the same time, a 2–3 lb/day or 5 lb/week threshold, and a phone number to call before the ankles swell. Weight change is the earliest reliable signal of decompensation and is fully within her control.
3. Access and depression. Book cardiology within 7 days and solve the transport problem (Medicaid non-emergency medical transportation benefit, volunteer driver program, or telehealth if the practice supports it). Refer for depression treatment or at minimum notify the PCP of the PHQ-9.
Reasoning: sequence by time-to-harm and modifiability. Medication error and unrecognized volume overload are the two fastest routes back to the hospital; transport is the barrier that converts a good clinical plan into a missed appointment.
3. At your second contact, Mrs. R declines a home visit: "I've lived here forty years. I'm fine." What is your response?
Read the worked answer
Refusing a home visit is not refusing case management. Treat it as a negotiation, not a termination criterion.
- Explore the reason before responding to the request. Use reflective listening: "Forty years is a long time. What is it about someone coming into the apartment that doesn't sit right?" The objection is often privacy, fear of being judged, or fear of being moved out.
- Offer alternatives rather than withdrawal: telephone and video check-ins, meeting at the cardiology clinic or a community site, a home visit paired with something she values (e.g., a pharmacist-led med review), or a visit from a community health worker rather than a nurse.
- Protect the safety net regardless: confirm she can reach help in an emergency, has a working phone, and knows the number to call for worsening symptoms. Ask permission to include her daughter in a call.
- Document the offer, her decision, and the plan - and keep her open on your caseload.
Reasoning: self-determination governs. An adult with capacity may decline services, and refusing one service does not justify closing the case. Closing it would remove the only safety net precisely because she asserted autonomy.