A coordinated care plan is a written or electronic plan designed to assist a patient or patients to wit their daily healthcare requirements. The plan outlines the patients’ short term and long-term needs, recovery goals, as well as the persons responsible for every part of the plan. The coordinated care plan facilitates communication between the individuals responsible for taking care of the patient. The care plans can also be used by patients and physicians to manage a multiple medical therapies prescribed by a healthcare professional (Overgaard, et al., 2016) Median Hill hospital is dedicated towards providing quality medical care to all its inpatient and outpatient clients. The hospital’s staff is trained to attend to all kinds of medical conditions while ensuring that the patients are attended to in the most humane manner possible. The dedication and professionalism of the nurses and the doctors is worth admitting. However due to recent budget cuts, the hospital’s case management staff has been relocated to the inpatient setting. My task as the lead nurse is to take on the role of care coordination. While I am a bit unsure of the process, I am sure my previous nursing roles have prepared me adequately for r the challenge ahead. Otero et al. note that coordinated care plans play a crucial role in patients’ recovery process (Otero, et al., 2015) . For this reason, I aim at ensuring that the coordinated care plan will be distinct from the selected patient’s daily provision of care.
My patient’s name is Sarah and she is 65 years old. Sarah was diagnosed with Fibrotic lung disease tree years ago. In the past six months, her condition worsened and therefore she was admitted for three months in the Median Hill Hospital. She spent three months in the hospital but got discharged after a while. However, she still needs continuous medical attention. Below is Sarah’s preliminary care coordination plan.
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Goal Setting : Sarah experiences breathlessness and fatigue most of the times. She also develops a dry cough which has proven difficult to treat. Over the past one month, Sarah has been depressed after learning that she has less than three years before she succumbs to the disease (Pérez, et al., 2018) . As a result, her condition has worsened.
Highest risk for readmission: Sarah experiences a sudden loss of life. Moreover, the rapidly a support deteriorating disease is giving her little time to cope and adjust. Most importantly, Sarah lacks a support structure.
Major problems
Anxiety
Depression
Resistance to medicine
Patient’s short term needs
Sarah needs to be reassured that she will be fine despite her deteriorating condition.
Sarah needs medicine to help her cope with the condition
Sarah needs to be relived of the side effects of pirfenidone and nintedanib
Sarah has to be put on depression therapy
Patient’s long-term needs
Sarah’s situation requires long-term care. She can no longer function by herself without help
Sarah needs psychological counselling that can help her cope with her condition.
Sarah needs a strong support system that can help her develop a positive attitude towards life.
Priorities for Health
Given that Sarah has complained about adverse side effects from the use of pirfenidone and nintedanib, I will suggest an alternative way of taking the medicine to reduce the side effects. In particular, Sarah will be required to take the tablets during meals but not on an empty stomach (Shaw, Marshall, Morris, Hayton, & Chaudhuri, 2017) . This process should start immediately.
Sarah will undergo a supervised dosage reduction to reduce the adverse effects of the drugs.
Sarah’s cough will subside once we reduce her dosage and put her on alternative medicine
Sarah will have a positive outlook towards life
Coordination Requirements
General requirements
Teamwork
Medication management
Health information technology
Advanced team care
Telemedicine
Specific activities
Transition of care from inpatient to outpatient
Linking to community resources
Aligning patient needs with population resources
Creating a proactive care plan
Assessing the patient’s need and goals
Responsibilities
I have chosen to work with one nurse who will oversee Sarah’s recovery process. The nurse will assist me with monitoring Sarah’s condition and providing timely reports on her recovery.
I will also work with Sarah’s family to ensure that she gets the required care while at home. In particular, I will establish a working relationship with Sarah’s husband. The husband will ensure that Sarah take her medicine with food as opposed to an empty stomach (Sampson, Gill, Harrison, Nelson, & Byrne, 2015) .
Available community resources for a safe and effective continuum of care
Sarah lives in a community where employers allow employees to recover from a medical condition before they resume work. As such, Sarah will have to undergo the recovery process before she resumes her work at a local bookstore.
Sarah’s community has voluntary counsellors who can help Sarah to recover and to live a productive life in the few years she has left.
The community has rehabilitation services for sick and elderly patients
The community has healthcare workers that help manage costly health conditions. Moreover, they identify new issues that might not be identified from a typical hospital visit.
References
Otero, C., Luna, D., Marcelo, A., Househ, M., Mandirola, H., Curioso, W., . . . Villalba, C. (2015). Why Patient Centered Care Coordination Is Important in Developing Countries? Yearbook of Medical Informatics, 10 (1), 30-33. doi:10.15265/IY-2015-013
Overgaard, D., Kaldan, G., Marsaa, K., Nielsen, T. L., Shaker, S. B., & Egerod, I. (2016). The lived experience with idiopathic pulmonary fibrosis: a qualitative study. European Respiratory Journal , 1472-1480. doi:10.1183/13993003.01566-2015
Pérez, E. F., Zelarney, P., Thomas, S., Shoop, D. A., Munson, J. L., Johnson, K. D., . . . Meadows, S. (2018). An educational initiative to improve the team-based care of patients with idiopathic pulmonary fibrosis. ERJ Open Research, 4 (1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814766/
Sampson, C., Gill, B. H., Harrison, N. K., Nelson, A., & Byrne, A. (2015). The care needs of patients with idiopathic pulmonary fibrosis and their carers (CaNoPy): results of a qualitative study. BMC Pulmonary Medicine, 15 , 155. doi:10.1186/s12890-015-0145-5
Shaw, J., Marshall, T., Morris, H., Hayton, C., & Chaudhuri, N. (2017). Idiopathic pulmonary fibrosis: a holistic approach to disease management in the antifibrotic age. Journal of Thoracic Disease, 9 (11), 4700–4707. doi:10.21037/jtd.2017.10.111
