In most countries, nearly half the population lives with at least one chronic infection, and the presence of multiple chronic illnesses across populations calls for ongoing management and attention. Care coordination is an efficient model in the management of such conditions, defined as a person-centered and assessment-based based approach to interdisciplinary care. It is a plan which integrates healthcare services with social support services cost-effectively to ensure that it meets personal needs as well as preferences. It takes a person-centered approach whereby the patient together with the family are empowered to manage behavioral health, physical health, and any inherent psychological needs. Besides addressing a patient’s medical needs, therefore, the proposed care plan encompasses services from various social support institutions to bridge any available care gaps. The patient’s needs must be assessed in a culturally-relevant way to determine the health management preferences and strengths. In person-contact is also emphasized in this plan as a means of devising and delivering successful interventions. The primary care physician providing for the patient’s needs will also work closely with other care coordinators because of the inherent factors which affect the degree of coordination between the physician and other providers. The first barrier is the lack of face-to-face interaction among the care coordination team members, whereas the second is the lack of consistency among some members of the team. Education and monitoring of the patient take center-stage, while treatment assumes an evidence-based model. At Median Hill hospital, Sarah is admitted for fibriotic lung disease which has worsened over time, requiring proper management through pharmacological interventions. She has other co-occurring conditions which can for behavioral management and these include depression and anxiety.
Pharmacological Interventions
The continued use of nintendanib and pirifenidone is necessary, which should commence immediately and continue until the symptoms dissipate. Considering the side effects that the patient has grappled with, however, solutions must be sought. Management of diarrhea and rashes must commence immediately as well but in case the side effects persist, alternative therapy may be sought after a duration of one month. Particularly, pulmonary rehabilitation will be sought as a means of enhancing lung functioning and improving the patient’s daily function. In case she remains on pharmacological therapy, taking the drugs alongside meals would aid in reducing some of the serious side effects that she experiences currently. Bendstrup and colleagues (2019) suggest that the most effective way of managing the side effects arising from the use fibrotic lung disease drugs is through the administration of such drugs after a meal as this would reduce stomach upsets which occasionally cause diarrhea. As part of the pharmacological treatment of the patient, therefore, the coordinated plan of care includes physical exercise programs, breathing strategies which enhance efficiency, counseling, and education regarding the management of her condition. It is a plan that brings together physical therapists, the primary care physician, Sarah’s family, and critical care nurses. A framework of effective communication will be established within and outside the hospital to facilitate weekly follow-ups and ensure that she adheres to the breathing and physical exercise recommendations.
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The proposed pharmacological interventions also extend to the administration of antidepressants for the management of anxiety. Serotonin reuptake inhibitors will be prioritized because they lack side effects and besides, they have no contraindications when used alongside other medications such as nintendanib. Wittchen other scholars (2012) also recommend the use benzodiazepines, but these cannot serve as a first line of therapy because they are highly addictive and they may hinder effective treatment of fibrotic lung disease.
Psychological Interventions
Cognitive behavior therapy will be administered with the help of a qualified therapist, targeting distorted thinking patterns to assure the patient that she will effectively manage her conditions. Cognitive behavior therapy will begin immediately after the administration of the recommended interventions. The sessions will take place in the hospital setting at least once every week, and a total of 20 sessions will be required. It will explore the link between the patient’s thoughts, emotional reactions, and behaviors, and perhaps this will help in dealing with the symptoms of anxiety which she reports. There are basic tenets which cognitive behavior therapy targets and these include the patient’s core beliefs, negative automatic thoughts, and dysfunctional assumptions as reported by Pearsons (2012). These dysfunctional assumptions are rigid and conditional rules which an individual develops over time, and perhaps this is why the patient declines to take medications based on the assumption that she might not recover. Collaborative empiricism will be the guiding framework in the administration of this therapy, an approach that insists on the development of a meaningful therapeutic relationship between the therapist and the patient (Pearsons, 2012). The therapist must therefore work as a unified with the patient within the first two sessions to identify some of the maladaptive behaviors and thoughts which she has developed over time, and the primary goal will be the elimination of such behaviors. The therapist as a facilitator helps the patient in effectively defining the problem and using the available cognitive resources to bring change (Pearsons, 2012). It is a problem-oriented approach which focuses on the present problems and not the past causes of such a problem, and this is why it is effective in the management of conditions such as anxiety.
Transition of Care from the In-patient Department
Coordination will also be necessary in transitioning the patient from the in-patient department to the outpatient department where she can make occasional hospital visits or opt for telemedicine. Rather than the high dosage of 150g, 100mg will be administered for two weeks, after which a subsequent assessment will come in to ascertain whether she is fit for discharge from the in-patient department. Pharm and colleagues (2018) assert that three conditions must accompany the proposed transition and these include a determination of whether the patient meets the discharge criteria through full lung functioning and physical stability. Providing the patient and her informational caregivers the information needed for management of the existing conditions is also necessary. Lastly, ensuring that there is vigilant follow-up after discharge will be required, and this calls for the exchange of contact information, the willingness to advance telehealth, and working with community support resources such as the patient’s family to ensure she receives adequate care, moderate exercise, and a good diet. The transition of care plan will take place after completion of the two-week dose, but she must report to the facility weekly or invite the services of a therapist to help in managing anxiety.
Aligning the patient’s needs with population Resources
As a means of genuinely improving health and healthcare services to enhance treatment outcomes, leveraging the digital infrastructure is necessary, and it requires support from the health service providers, the patients, and the larger population (McGinnis, Powers, and Grossman, 2011). The digital infrastructure pieces that must be aligned and improved to assist Sarah include data which must be repurposed to fit her community needs. Accountable care organizations within her community will be notified of the patient’s needs as well because this forms the basis for providing coordinated care. It is such institutions that help in population health monitoring to ensure that the patient’s distorted thinking patterns do not trickle down to the family which is meant to offer meaningful social support. As a primary care physician, having an assigned nurse to monitor the patient’s progression over three months will ensure that timely updates facilitate a change of therapy where necessary, or a reduction of the medication dosages to alleviate the side effects.
Patient Support
Patient support services will be based on the assessment of needs within and outside the inpatient facility. Mail services, transport services, and assistive devices may be necessary, especially after developing lung problems which may hinder breathing processes. The goal of extending patient support services is to create an exceptional experience which speeds up the speed of recovery (Marbach & Griffie, 2011). All the healthcare staff involved in the coordinated plan must create an enabling relationship with the patient through constant communication to ensure that she develops a positive outlook towards life. Besides, creating a good relationship and communication strategy with the family will render follow-up processes easy, especially after the first one month of transition from the inpatient to the outpatient unit.
Summary
In summary, Sarah suffers from multiple conditions, and a coordinated approach to treatment is the most appropriate. It calls for interdisciplinary coordination between the primary care physician, a dedicated nurse, a physical therapist, and a counseling expert. The precise actions meant to manage her conditions include the provision of pharmacological treatments, management of the side effects that she experiences, the provision of therapy, utilization of community resources, and coordinated transition from the inpatient to the outpatient unit. These services notwithstanding, regular follow-up and patient education matter to the patient and the family as this aids in managing conditions such as anxiety.
References
Bendstrup, E., Wuyts, W., Alfaro, T., Chaudhuri, N., Cornelissen, R., Kreuter, M., ... & Vanuytsel, T. (2019). Nintedanib in idiopathic pulmonary fibrosis: practical management recommendations for potential adverse events. Respiration , 97 (2), 173-184
Marbach, T. J., & Griffie, J. (2011, May). Patient preferences concerning treatment plans, survivorship care plans, education, and support services. In Oncology nursing forum (Vol. 38, No. 3).
McGinnis, J. M., Powers, B., & Grossmann, C. (Eds.). (2011). Digital infrastructure for the learning health system: the foundation for continuous improvement in health and health care: workshop series summary . National Academies Press
Pham, H. H., Grossman, J. M., Cohen, G., & Bodenheimer, T. (2018). Hospitalists and care transitions: the divorce of inpatient and outpatient care. Health Affairs , 27 (5), 1315-1327
Persons, J. B. (2012). The case formulation approach to cognitive-behavior therapy . Guilford Press.
Wittchen, H. U., Kessler, R. C., Beesdo, K., Krause, P., Höfler, M., & Hoyer, J. (2012). Generalized anxiety and depression in primary care: prevalence, recognition, and management. The Journal of clinical psychiatry
