B.J. is a patient who was hospitalized

B.J. is a patient who was hospitalized for a stroke and is then sent home on home health services. The home health team has made their initial assessments and visits to the patient’s home, which is in rural Indiana. Multiple problems exist in several areas: medication management, risk for diabetic complications, nutrition, ability to self-care, social concerns, and rehabilitation needs. History of Present Illness B.J. is a 71-year-old white female who recently (< 1 month ago) suffered a right cerebrovascular accident with mild to moderate left hemiparesis and sensory loss. She was admitted to the hospital followed by a 10-day stay at the rehabilitation unit. By discharge, the patient achieved independence with mobility and transfers. Gait is CGA (contact guard assist) using a front-wheeled walker for up to 100 feet. The patient is returning home with her husband. Past Medical History Previous cerebrovascular disease was documented via MRI, showing three small strokes. In regard to her severe coronary artery disease, the patient underwent cardiac catheterization 8 months ago, which showed severe diffuse coronary artery disease, not suitable for revascularization. Patient has poorly controlled long-standing Type 2 diabetes with multiple microvascular and macrovascular complications. Diagnosis Right cerebrovascular accident with mild left hemiparesis Type 2 diabetes mellitus with peripheral neuropathy, gastroparesis, nephropathy, and retinopathy Hypertension Coronary artery disease Hyperlipidemia Stage 3 chronic kidney disease Status post surgeries: total abdominal hysterectomy, 1992, and cholecystectomy, 1984 History of poor medication adherence Discharge Medication List: Warfarin 5 mg, 1 tablet po once daily Aspirin 81 mg, 1 tablet po once daily Metformin 500 mg, 2 tablets po twice daily Glipizide XL 5 mg, 2 tablets po each morning and 1 tablet each evening prior to meals Simvastatin 20 mg, 1 tablet po once daily Amlodipine 10 mg, 1 tablet po at bedtime Isosorbide 20 mg, 1 tablet po once daily Metoprolol XL 25 mg, 1 tablet po once daily Furosemide 40 mg, 1 tablet po each morning Metoclopramide 10 mg, 1 tablet po 30 minutes prior to meals and at bedtime Allergies: No known drug allergies B.J. had been established on lispro (Humalog™) and glargine (Lantus™) insulin by her endocrinologist. However, the patient discontinued her Lantus™ and used only Humalog™ on a sporadic basis, preferring to take only "natural medicines" for her diabetes. Oral agents were, again, initiated with metformin and glipizide even though they had not controlled her diabetes previously, but with hopes for better adherence to therapy this time. Action Items Here are the items to address: What treatment and follow-up plan would you recommend in this case? What patient education would you provide this patient? What does her husband or other caregivers need to know from you as the PCP? What tests or diagnostic tools would you consider in this case, if any? Why or why not ?

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