Written organization of the case vignette of  Mr. Glover

The clinical data related to the scoring can also be organized in the
following way; this may be helpful for example when the patient should
be referred to a different facility. In the electronic version, the
above presented and computer-entered clinical information is
automatically organized in the hereafter-presented way (see also
paragraph "How to know more about the INTERMED").  

Biological risks: Mr Glover is a 55 years old male, who has been
admitted through the emergency room to a cardiac ward for a myocardial
infarction complicated by a ventricle tachycardia; the cardiac condition
requires immobilization. Mr Glover suffers from a chronic disease
(hypertension), recently complicated by another chronic condition (heart
disease due to a myocardial infarction). There have not been other
episodes of physical illness in the last five years.  

Social risks: Over the last five years, work has dominated his life to
such extend that it has negatively influenced the relationship with his
wife; they live separated since a month. The patient is currently living
alone on a hotel room. Beyond a sister and a colleague, he does not have
people who may support him, nor does he have time for or interest in
leisure.

Psychological risks: From a psychological perspective, Mr Glover has
denied his cardiac condition and tends to reduce tension with smoking
and drinking. His history indicates an earlier episode of mood disorder
and impaired coping after the separation of his first wife. Currently he
presents substance abuse problems concerning tobacco and alcohol and a
depressive disorder. This psychological state interferes with his
compliance to medical treatment as reflected in the recent inability to
take medication on a regular basis and his behaviour, which represents a
risk for his cardiac condition.

Health care risks: In the last 5 years Mr. Glover has been admitted for
a first myocardial infarction and has been treated by a primary care
physician and a cardiologist. At the moment he does not see any medical-
or other caretakers. His trust in doctors has been negatively influenced
by two earlier incidents.
 

Prognoses

Biological prognosis: the patient suffers of a chronic condition and
might in the future be subjected to permanent substantial limitations in
activities of daily living  

Psychological prognosis: the patient has a psychiatric disorder
requiring psychiatric care; he suffers from depression, which is
complicated by various other conditions, such as substance abuse, social
isolation and a serious medical illness.

Social prognosis: due to his current physical condition and the social
situation, the patient has a serious risk of a temporary admission to a
facility.  

Health care: Taking into account the various risks factors in the
various domains, the patient has to be considered as complex requiring
different specialist consults and care coordination, including mental
health care.  


Treatment plan 

Biological level: Depending on the stabilization of the circulation in
the first 24 hours, patient's cardiac condition will be evaluated
according to protocol. The cardiologist regards his postdischarge
functional prognosis to be in the range of New York Heart Association
classification 1-2. For the first 24 hours the patient should be
monitored for physical symptoms of alcohol withdrawal by observing his
sleeping patterns, although the risk seems relatively low. Given the
overall situation, a low dosage of benzodiazepines will be prescribed
for 3-5 days to prevent distress, which could negatively influence his
cardiac condition. After stabilization, the patient should be referred
to a cardiac rehabilitation program, followed by regular medical
appointments. 

Psychological level: a psychiatric consultant should assess the patient
and evaluate the interrelation between coping, compliance, substance
abuse and depression. As a result of this assessment it should be
decided, who should initiate at what time and what kind of treatment. As
compliance with treatment is crucial in this patient, the primary focus
of the intervention should be to motivate the patient for psychological
treatment. Depending on the results of the contacts with the sister and
his wife, the integration of these persons in the psychiatric treatment
plan should be considered.  

Social level: the patient's wife should be invited to further explore
his social and relational situation. Based on the results of this
exploration, the outcome of his physical condition and the results of
the psychiatric assessment, decisions on the location of post-discharge
treatment planning should be made: psychiatric transfer, rehabilitation
clinic or ambulant treatment.   

Health care level: A multidisciplinary case conference should be
organized in the next days to integrate the results of the different
consultants (rehabilitation, psychiatry and social work); later an
assigned case manager should coordinate the treatment program.