Following the ankle fusion and bilateral knee replacement, patient was hospitalized twice for GI bleeding and visited the ER for confusion due to metabolic imbalance
10 office visits to his HTC in the past 6 months, including laboratory monitoring for bleeding episodes and HCV infection
HTC nursing staff has followed up with 18 telephone contacts for bleeding and medication-related issues
Intensive PT over the past 2 years for post-surgical rehab
Social worker has followed-up in the past 6 months, including a mental health consultation for major depressive disorder (MDD) related to health issues and increasing disability