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The first step in any effective project is planning.
The first step in any effective project is planning. This assessment provides an opportunity for you to strengthen your understanding of how to plan and negotiate the coordination of care for a particular health care problem. Include physical, psychosocial, and cultural considerations for this health care problem. Identify and list available community resources for a safe and effective continuum of care.
Preparation:
Scenario
Imagine that you are a staff nurse in a community care center. Your facility has always had a dedicated case management staff that coordinated the patient plan of care, but recently, there were budget cuts and the case management staff has been relocated to the inpatient setting. Care coordination is essential to the success of effectively managing patients in the community setting, so you have been asked by your nurse manager to take on the role of care coordination. You are a bit unsure of the process, but you know you will do a good job because, as a nurse, you are familiar with difficult tasks. As you take on this expanded role, you will need to plan effectively in addressing the specific health concerns of community residents.
To prepare for this assessment, you may wish to:
· Review the assessment instructions and scoring guide to ensure that you understand the work you will be asked to complete.
· Allow plenty of time to plan your chosen health care concern.
Develop the Preliminary Care Coordination Plan
Complete the following:
· Select one of the health concerns in the Assessment 01 Supplement: Preliminary Care Coordination Plan (ATTACHED BELOW) as the focus of your care coordination plan. In your plan, please include physical, psychosocial, and cultural needs.
· Identify available community resources for a safe and effective continuum of care.
Full Answer Section
Interventions:
Medication Management: Educate on prescribed medications (oral hypoglycemic agents, insulin if needed), including dosage, administration, side effects, and importance of adherence. Coordinate with the prescribing physician.
Nutrition Counseling: Refer to a registered dietitian for personalized meal planning, emphasizing portion control, healthy food choices, and strategies for eating on a budget. Address cultural food preferences and cooking habits.
Physical Activity: Encourage regular moderate-intensity exercise (e.g., brisk walking, cycling) for at least 150 minutes per week. Explore options for physical activity that fit Mr. Johnson's busy schedule and are accessible in his community.
Self-Monitoring of Blood Glucose (SMBG): Educate on proper technique, frequency, and interpretation of results. Provide a logbook or app for tracking.
Foot Care: Educate on daily foot inspection, proper hygiene, and nail care to prevent foot ulcers.
Smoking Cessation: If applicable, provide resources and support for smoking cessation.
II. Psychosocial Needs:
Problem: Stress related to managing diabetes, potential for depression or anxiety, challenges with lifestyle changes, limited social support.
Goals: Improve coping skills, reduce stress, enhance motivation for self-management, increase social support.
Interventions:
Diabetes Education: Provide comprehensive education about T2DM, its management, and potential complications. Address Mr. Johnson's specific concerns and questions.
Counseling/Support Groups: Refer to a counselor or diabetes support group to address emotional challenges and provide peer support.
Stress Management Techniques: Teach relaxation techniques (e.g., deep breathing, mindfulness) and explore stress-reducing activities.
Motivational Interviewing: Use motivational interviewing techniques to empower Mr. Johnson to make positive lifestyle changes.
Family Involvement: Encourage family involvement in diabetes management and support.
III. Cultural Needs:
Problem: Cultural beliefs and practices related to diet, health, and illness may influence diabetes management.
Goals: Provide culturally sensitive care that respects Mr. Johnson's beliefs and preferences.
Interventions:
Culturally Appropriate Education: Tailor diabetes education to Mr. Johnson's cultural background, considering his preferred language, health beliefs, and dietary habits.
Community Resources: Connect Mr. Johnson with community resources that cater to his cultural group, such as cultural food banks or support groups.
Interpreter Services: If needed, provide interpreter services to ensure effective communication.
IV. Community Resources:
Diabetes Education Programs: Local hospitals, clinics, or community centers may offer diabetes education classes.
Registered Dietitians: Referral for personalized meal planning.
Exercise Programs: Community centers, gyms, or YMCA/YWCA may offer affordable exercise programs.
Support Groups: Local diabetes associations or hospitals may host support groups for people with diabetes and their families.
Mental Health Services: Referral to a counselor or therapist for stress management, depression, or anxiety.
Food Banks/Pantries: Assistance with access to healthy food.
Transportation Assistance: If transportation is a barrier, explore options for transportation assistance to medical appointments.
Online Resources: Provide links to reputable websites such as the American Diabetes Association (ADA) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
Pharmacists: Consult with pharmacists regarding medication management, cost-effective options, and potential drug interactions.
V. Care Coordination Process:
Initial Assessment: Comprehensive assessment of Mr. Johnson's physical, psychosocial, and cultural needs related to his diabetes.
Care Plan Development: Collaboratively develop a care plan with Mr. Johnson, incorporating his goals, preferences, and available resources.
Referrals: Make referrals to appropriate community resources.
Follow-up and Monitoring: Regularly follow up with Mr. Johnson to monitor his progress, address any challenges, and adjust the care plan as needed.
Communication: Maintain communication with all members of the healthcare team, including the physician, dietitian, counselor, and other specialists.
Documentation: Document all care coordination activities in Mr. Johnson's medical record.
This preliminary plan provides a framework for coordinating Mr. Johnson's diabetes care. It's crucial to individualize the plan based on his specific needs, preferences, and available resources. Ongoing monitoring and evaluation are essential to ensure the plan's effectiveness and make necessary adjustments.
Sample Answer
Let's develop a preliminary care coordination plan, focusing on Diabetes Mellitus Type 2, one of the health concerns listed in your hypothetical supplement.
Preliminary Care Coordination Plan: Type 2 Diabetes Mellitus
Patient: (Hypothetical) Mr. Johnson, a 55-year-old African American male, recently diagnosed with T2DM. He has a history of hypertension and obesity. He is a single father of two teenagers and works two jobs to make ends meet. He expresses concern about managing his diabetes given his busy schedule and limited cooking skills.