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* 1.  A 74 year old Medicare fee for service beneficiary with history of hypertension, hyperlipidemia, schizophrenia, type II diabetes mellitus, non-insulin requiring, with A1c of 4.5 presented to ED with complaints of generalized weakness for the past 1 to 2 weeks. Patient had been hospitalized 9 days prior w/ similar complaints and was discharged home with home health services, however patient continues to have weakness and recurrent falls at home. BP 175/62, O2 Sat RA 96%, Pulse- 109.

Glucose: 105, BUN 21, creatinine 0.8 Calcium 11, sodium 146, Potassium 3.6, Bicarb 28, albumin 4, Total protein 7.8, ALT 34, AST 16, ALP 100, Bilirubin 0.7, CK 122, Phosphorus 3.1, magnesium 1.9, TSH 1.5, free thyroxine 1.16, Trop I 48.5, WBC 8.14, hemoglobin 13.2, MCV 83, platelet count 226.

The patient was placed outpatient with observation for evaluation of rehab placement evaluation since failed outpatient, hypercalcemia, and diabetes medication adjustment.  PT evaluated and recommended SNF placement, but because of patient’s hx of schizophrenia, patient required Level II PASRR.  Evaluation from state, for Level II PASRR evaluation, stated it would take 7-10 days to evaluate patient for placement. 

Patient was then transferred to sister hospital while awaiting placement as acute medical issues had now resolved and continued in observation status.  Main hospital was not in a surge capacity issue at the time, however due to waiting period was worried that they may have a bed issue and wanted to move the patient just in case. Patient sat at the sister hospital in observation for 10 days awaiting placement approval from the state for transfer. 

What is the proper level of care for the first hospitalization?

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* 2. Does the patient transfer from one hospital to another hospital change patient’s status?

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* 3. As a physician advisor, you are asked to re-evaluate the case on day 3 after patient has crossed 3 Midnights in observation status while pending PASRR and pending placement. What status would you suggest for this patient?

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* 4. Would your answer regarding patient status be different if the patient had Medicare Advantage instead of Medicare fee for service?

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