2. Mr. Yeager is a 70-year-old man with a history of an aortic valve replacement, rheumatoid arthritis, and recurrent sinusitis. He lives independently with his wife. His medications include warfarin, metoprolol, gabapentin, infliximab, and acetaminophen. He is followed by a nurse practitioner at his primary care clinic, a cardiologist in his cardiology clinic, a physician assistant in his rheumatology clinic, an otolaryngologist in his ENT clinic, and a pharmacist at the hospital's anticoagulation clinic. He also attends twice weekly physical therapy as part of his continuing recovery from recent spinal surgery. His cardiologist adjusts his blood pressure medications, his orthopedic surgeon managers his postoperative care, his rheumatology PA monitors his pain and anti-inflammatory medications, and the pharmacist adjusts his warfarin. At no point in time do these care providers communicate with one another. Over the weekend, Mr. Yeager develops symptoms of a recurrent sinus infection. He calls the nurse practitioner who is on call for his ENT. She has access to his ENT clinic records, but not his primary care records. Based on his symptoms, she prescribes him amoxicillin/clavulanate for a presumed sinus infection. She is unaware of the increased risk of bleeding for Mr. Yeager with the medication interaction of these two medications. Mr. Yeager's wife asks the NP if she would contact Mr. Yeager's cardiologist, as she is aware that Mr. Yeager is on several cardiac medications, and the NP responds with "I'm sure this antibiotic will be fine." The following week Mr. Yeager presents for his regular physical therapy. The therapist notes that he seems fatigued and decides to cut his therapy short for the day. As Mr. ­ Yeager is finishing his exercises, he trips on the edge of the treadmill and falls, striking his face and causing a nosebleed. Despite repeated attempts by clinic staff, they are unable to stop the bleeding and eventually transport him by ambulance to the emergency department (ED), where he continues to bleed. At the ED, his blood pressure is 88/40, with a heart rate of 55. His nose is packed to stop the bleeding, and his hematocrit is found to be 23 with an INR of 9.5. He is admitted to the intensive care unit, where he receives a transfusion of fresh frozen plasma to reverse his coagulopathy and red blood cells for his severe blood loss. He is discharged from the hospital 8 days later with diagnoses of a fall due to postoperative weakness combined with hypotension secondary to his blood pressure medication, and severe nasal hemorrhage secondary to nasal trauma. At no point before Mr. Yeager's discharge are there any discussions about altering any of the medications that Mr. Yeager will resume taking upon his return to home.

   Questions:

   1. Is there a primary patient and family centered care challenge in this scenario?
      1. If so, what is it?
      2. If not, then what elements in this scenario are patient and family centered?
      3. If not, what do you think the challenges could be if the patient and family centered elements were missing?
   2. Is the challenge with the patient, the family, or a health team member? Explain why.
   3. Who is responsible for creating the challenge?
   4. Who is responsible for making the necessary changes to address the challenge?
   5. What opportunities are available for successfully addressing this challenge?
   6. What resources (human, financial, time, other) will be needed?
   7. What barriers might prevent a successful outcome?
   8. What do you believe a successful patient and family centered care outcome looks like?