CAD Patient: Jessie Gonzalez

A next-day IV antibiotic referral, Day 0 to Day 1

Age 75North Ridge, CARetired

Jessie was born in Houston, TX in 1950, he had a modest childhood and he is a Vietnam Veteran, who worked as a Pressman printing the newspaper. He is divorced with 2 sons, Pasha and Andrew, with Pasha being the main care taker. The sons currently don't get along and frequently fight over who can watch their father. Patient has just been D/C'd from the hospital and needs IV-ATB from a HH provider.

Today As it could be

Today · Stage 1 · Day 0: 4/1/2025

Inpatient Setting

Inpatient / Case Management

Jessie leaves the hospital. His case manager promises a nurse tomorrow.

Woodland Hills inpatient patient is discharged
CM discharges patient and puts in a HH referral for next-day IV-ATB
Patient caregivers (sons) believe at this point patient was dc'd too soon
CM does not contact KP HH beforehand to see if they can take next-day

As it could be (proposed)

Discharged with a confirmed visit

Before Jessie leaves, his case manager has confirmed with the agency that a nurse can come tomorrow, and tells him which number will call.

Immediate
CM Scripting: 1) Don't overpromise 2) specify # that will contact pt
prevents 2 moments
Possible
At D/C CM is equipped w/ confirmed info from agency RN to see next-day
prevents 3 moments
Possible
AVS should include accurate HH info
prevents 2 moments
Possiblefrom Stage 5
Received automated KP message w/ expectations (phone + text)
prevents 2 moments

Today · Stage 2 · Day 0: 4/1/2025

Referral Intake

Jessie's phone rings three times from a number he does not know. He picks up on the third.

Bot processes referral, is checked, goes into Ready to TIF WQ
Intake calls patient 3 times to TIF (twice on day 0, once on 4/2)
Pt picks up on 3rd call
Intake sends to agency scheduling WQ
Patient does not answer because of unknown #

As it could be (proposed)

One call, answered

Intake calls the number Jessie confirmed at discharge. He is expecting the call and picks up the first time.

Immediatefrom Stage 1
CM Scripting: 1) Don't overpromise 2) specify # that will contact pt
prevents 2 moments
Immediate
Communicate w/ patient needs to answer phone calls
prevents 1 moment
Immediate
Confirm patient phone number on file
prevents 1 moment
Possiblefrom Stage 1
AVS should include accurate HH info
prevents 2 moments

Today · Stage 3 · Day 1: 4/2/2025 @10AM

Agency Scheduling

Nine o'clock passes. No nurse. Jessie's son calls to ask where the dose is.

Agency resource RN cannot schedule next-day @12PM
Agency decides to outsource CAD @12PM
Goes to Ready to Outsource WQ @12:30PM
MISSED TP: IV was supposed to be delivered at 9AM
Son of patient calls agency about missed dose
Too much back and forth happening before decision is made

As it could be (proposed)

Visit scheduled for 9AM

The agency can see its availability at a glance. The 9AM visit is scheduled before Jessie gets home.

Immediatefrom Stage 1
CM Scripting: 1) Don't overpromise 2) specify # that will contact pt
prevents 2 moments
Immediate
Use templates to identify if staff have availability to OS quicker
prevents 1 moment
Possiblefrom Stage 1
At D/C CM is equipped w/ confirmed info from agency RN to see next-day
prevents 3 moments
Possible
CAD has reliable capacity
prevents 6 moments

Today · Stage 4 · Day 1: 4/2/2025 @1PM

Arranging CAD service

KP CAD

A partner agency says yes at 1PM, then backs out at 3:30PM. Jessie never got the text.

Call CAD partners to staff same day IV
CAD partner "Jay's HH" agrees to staff at 1PM
Send to WQ #4 & goes to outsource team (not CAD)
OT initiates auth + docs and sends to "Jay's HH"
System sends txt to Chuy w/ info on CAD partner
Jay's HH calls KP CAD, say they can no longer staff @ 3:30PM
Chuy did not sign up for texts, didn't get info

As it could be (proposed)

No scramble needed

No scramble for a partner. KP CAD has the capacity, and Jessie already has the plan by phone and text.

Possiblefrom Stage 1
AVS should include accurate HH info
prevents 2 moments
Possiblefrom Stage 3
CAD has reliable capacity
prevents 6 moments
Possiblefrom Stage 5
Received automated KP message w/ expectations (phone + text)
prevents 2 moments

Today · Stage 5 · Day 1: 4/2/2025

End of day scramble

KP CAD

KP CAD calls. Jessie's son answers, upset. A nurse finally arrives at 9:30PM.

KP CAD calls Chuy and son answers
KP CAD finds new agency to staff @5:30PM
Nurse shows up @9:30 PM to conduct care
KP CAD calls patient
KP CAD calls multiple agencies (has to "fish")

As it could be (proposed)

Care starts on time

The nurse arrives at 9AM as promised. Jessie's dose is on time and his sons only hear a confirmation.

Possible
Received automated KP message w/ expectations (phone + text)
prevents 2 moments