A group of hospital administrators at a tertiary care center is interested in optimizing quality-related outcomes, including length of hospitalization and patient functional status for high-risk patients undergoing neurosurgical procedures.  Patients at highest risk for poor outcomes include those who are age >65 and have multiple medical comorbidities, including hypertension, diabetes, coronary artery disease, and heart failure.  The administrators are considering methods to coordinate care between the attending surgeon and a hospitalist-led, multidisciplinary team.

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Which of the following team-based approaches is associated with improved quality of care?

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Hospital administrators decide to implement a team-based care model that involves comanagement of surgical patients by surgeons and a hospitalist-led, multidisciplinary team that includes physical therapists, a social worker, pharmacists, and a nurse case manager.  A series of team meetings is held to define team goals, member roles, and methods for tracking desired quality and outcomes data.  Which of the following approaches is recommended to improve team performance and clinical quality?

A 24-year-old woman comes to the office accompanied by her caseworker.  This is the first time that she has been seen in the office, and she appears mildly anxious.  However, she quickly relaxes once the female physician enters the room.  The caseworker reports that the patient would like to discuss contraceptive options as she has become sexually active with her boyfriend.  Medical history is remarkable for moderate intellectual disability and surgical repair of a cardiac defect as an infant.  The patient says, “I would like to go on birth control.  I want a baby one day but not until I am married.”  The caseworker reports that the patient’s mother, who was unable to attend the appointment, is extremely concerned about the patient’s plan.  The mother wants the patient to have a tubal ligation as she does not think her daughter would ever be able to care for a child.  The patient becomes tearful and says, “My mom doesn’t know what’s best for me.  I know I can be a good mom.”

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Which of the following is the most appropriate next step in assisting the patient with these decisions?

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The patient reports that she does not have a guardian, and the caseworker confirms that the patient is responsible for her own decision making.  The caseworker provides additional information regarding the patient’s level of functioning.  She states that the patient lives in a group home and has a female roommate.  The patient plans to move in with her boyfriend, who has been diagnosed with borderline intellectual functioning.  The patient says, “My boyfriend is very nice and helps me a lot.  When we live together we can do the shopping ourselves.  He has his own job and works in the supermarket 3 days a week.  His sister is very nice, too, and she visits him every week.  She said that there is an injection I can have so that I don’t get pregnant until we are married.”  The physician educates the patient regarding contraception in simple terms and reviews the various birth control options, including depot progesterone injections.  The patient responds, “I don’t know.  Whatever you recommend, doctor.”  Which of the following would be the most appropriate response to this patient?

A 28-year-old woman with a diagnosis of glioblastoma multiforme has recently decided to transition to hospice care following intracranial surgery and a course of chemotherapy.  She has been informed by her oncologist that her prognosis is poor and that she will likely not live more than 6 months.  The physician overseeing the hospice team visits the patient’s home for a follow-up.  During this visit, the patient mentions that she has been having second thoughts about choosing hospice care and, after speaking with family members and friends, feels that this would be “giving up.”  Her twin brother will be getting married in 8 months and she wants to attend his wedding.  She has consulted 2 other oncologists who are experts in the field of glioblastoma for second opinions; they recommend an experimental life-prolonging chemotherapy regimen.  She says, “I feel like I have to give this a try.”

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Which of the following responses by the hospice physician would be most appropriate?

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Approximately 8 weeks later, the hospice team is contacted by the patient’s twin brother.  He says that the experimental treatment did not go as planned and the patient suffered multiple complications, including toxic epidermal necrolysis, respiratory failure, and ischemic brain damage that required a stay in the intensive care unit.  A ventriculoperitoneal shunt was placed due to increased intracranial pressure.  All family members are in agreement that the patient should return to hospice for comfort care.  The patient is unable to indicate whether she wishes to return to hospice or continue pursuing curative treatments.  Which of the following is a contraindication to the patient returning to hospice?

A 15-year-old girl comes to the office accompanied by her mother for a routine well-child visit.  The patient states that she is doing well and has no health concerns.  While speaking in private, she discloses that she has had sexual intercourse several times with a boy in her class.  The patient believes she may be in love and says that the sex is consensual.  Her partner is using condoms.  Physical examination is normal and urine pregnancy test is negative.  Routine laboratory screening for common sexually transmitted diseases is performed, and the patient is educated about safe sex and contraceptive options.  When the physician inquires if her parents are aware that she is sexually active, the patient says, “I would never tell them.  They’re very religious, and having sex before marriage is totally out of the question.  They would be furious if they knew.”  The patient asks the physician to say nothing to her parents.

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Which of the following is the most appropriate response to the patient?

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The patient is encouraged to contact the physician with any further questions and concerns.  She returns 6 months later for a precamp physical and says that she continues to be sexually active and is now in a relationship with the same individual from her school.  With further questioning, she shares that her boyfriend is in fact not a classmate but is her 22-year-old high school art teacher.  The patient mentions that her boyfriend has been very supportive in developing her artistic ability and is helping her decide where to apply for college.  The patient states that the relationship is consensual and says, “We both have really strong feelings for each other, and we’re waiting for the right time to let everyone know.”  Which of the following is the most appropriate course of action?

A 70-year-old woman is brought to the office by a friend who became concerned at finding her very weak and pale during a recent visit.  The friend had not seen the patient in more than 6 months and was shocked at her condition.  The patient says, “I feel very tired and have to sit down a lot to rest.”  She has had these symptoms for the past 10 months, but they are becoming progressively worse.  She was diagnosed with primary myelofibrosis 2 years ago.  The patient was not offered bone marrow transplantation due to her age; instead, she has received blood transfusions on more than 10 occasions, as well as erythropoietin and androgens, which have yielded poor results.  She has no other medical problems and takes no other medication.  The patient is widowed and lives with her son, who cares for her.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 110/min, and respirations are 20/min.  She appears pale and undernourished, with significant muscular wasting.  Auscultation reveals tachycardia.  Hepatosplenomegaly is present.  Laboratory results are as follows:

Three months ago, when her hemoglobin level was 8.0 g/dL and her hematocrit was 24%, the patient stated that she did not want any more blood transfusions or treatment.  She understands that her condition is worsening but has not changed her mind, and continues to refuse any type of therapy.  Which of the following is the most appropriate course of action?

A 28-year-old man comes to the office due to shoulder and back pain.  He works in a warehouse and is accompanied by his supervisor, who insists on remaining in the office to assist the patient with communication, although the patient is a native English speaker.  The supervisor explains that the patient can no longer perform his job due to the pain and that he is willing to cover the treatment costs because the patient has no health insurance.  When interviewed in private, the patient makes poor eye contact, appears anxious, and gives brief responses.  He describes back pain and an inability to move his right shoulder above his head but cannot remember how this happened when asked for details.  Medical history is noncontributory.  Vital signs are within normal limits.  Physical examination shows decreased range of motion of the right shoulder but is otherwise unremarkable.

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Which of the following is the most appropriate statement?

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When asked about his ability to leave the job, the patient admits that he is afraid to do so because he has no money, identification, or phone access.  The patient shares that another worker recently tried to quit but was forced to return.  He works 16 hours a day moving heavy boxes onto trucks but does not get paid.  The patient is given regular meals and shares a room in temporary housing with 3 other coworkers but does not know the address.  Which of the following is the most appropriate action in this patient’s care?