[Expert Solution]: A 75 yo female was admitted through the…

A 75 yo female was admitted through the emergency department following a fall at home with a fractured hip with dehydration and a history of heart failure. Following hip replacement surgery, Mrs. S. completed inpatient rehab and plans to return home. She complains of difficulty sleeping related to nocturanal urination, so she reduces her fluids in the evening and takes Ambien at bedtime. Mrs. S. has problems with discomfort due to constipation, which significantly decreases her appetite. Mrs. S.’s BMI is 15 and she lost 5 pounds in the past 3 months. Mr. and Mrs. S are on a fixed income and find it difficult to afford the nutritional supplement drinks recommended by the dietician. Mrs. S. lives with her husband who depends on her to cook, clean and do laundry, but can take care of his own physical needs. The S family relatives are supportive, but live approximately 1 hr from the family home, and visit intermittently on weekends. Mrs. S. has been told that many older people die within a year of a broken hip, and she feels anxious about the risk of dying when she gets home. Mr. and Mrs. S have been told they should consider moving to an assisted living facility, but Mrs. S would rather risk dying at home than having to move into a “nursing home.” Mrs. S knows her husband has been very forgetful and often gets lost, but does not want the family or doctor to know because she is sure they will force them move to a nursing home. Using the professional literature, research the State Action on Avoidable Rehospitalizations (STAAR) Initiative as the framework for how to provide care for the patient. Propose a strategy to meet each of the four points of the model that meets the needs of the case scenario provided for this week. This strategy must be consistent with the principles of (1) better home management of chronic conditions, (2) more use of community-based services or free online resources, and (3) best practice for the identified chronic condition. have a primary care focus for their strategies as an NP. Be creative about how to coordinate services between the hospital, PCP, specialty care provider(s), and patient.