Care Coordination and Discharge Plan for Congestive Heart Failure Patient

Discharge Plan for Congestive Heart Failure Patient
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Discharge Plan for Congestive Heart Failure Patient
Annotated Bibliography
Im, J., Mak, S., Upshur, R., Steinberg, L., & Kuluski, K. (2019). ‘The Future is Probably Now’: Understanding of illness, uncertainty and end‐of‐life discussions in older adults with heart failure and family caregivers. Health Expectations, 22(6), 1331-1340.
Considering the high risk of mortality in heart failure patients, communication about end-of-life to patients and the family is paramount when and after creating a discharges plan for congestive heart failure. According to the article, end-of-life communication is not standard, which causes continuous delivery of discordant care at the end of life for many patients. To bring to light the importance of communication and the need for patients and caregivers to have a common understanding of congestive heart failure, uncertainty, and the need to integrate them in hospitals to formulate appropriate discharge plans for patients. A thorough grasp of heart failure care does not always transfer into a comprehension of the repercussions of sickness. The capacity to adjust to illness-related problems may prevent older persons and families or careers from having EOL conversations. Future study is needed to investigate the effects of sickness in promoting earlier EOL discussion. The article provides essential information necessary for adopting a discharge plan to ensure he is not readmitted to the hospital.
Maciver, J., & Ross, H. J. (2018). A palliative approach for heart failure end-of-life care. Current opinion in cardiology, 33(2), 202.
The article explores how healthcare practitioners integrate guidelines and evidence-based practices in palliative and hospice care for end-of-life (EOL) patients. Heart failure programs are needed to include EOL palliative care integration. When doctors and other health workers create individualized discharge plans, they can share decision-making and determine measurements appropriate for palliative care patients. It is a way of improving the overall quality of life for EOL patients. The article will be significant in exploring ways to enhance the quality of living standards of heart failure patients at EOL. The information from this source will help identify the best care practices by the palliative and hospice care team to use in treating the patient at home.
Okumura, T., Sawamura, A., & Murohara, T. (2018). Palliative and end-of-life care for heart failure patients in an aging society. The Korean Journal of internal medicine, 33(6), 1039.
The article explores Asian demographics that are likely to grow fast in the coming years, resulting in a significant spike in congestive heart disease cases. The necessity for hospice and EOL care for old individuals with symptomatic heart failure is now acknowledged in geriatric communities. Nevertheless, pain management and proactive therapy for congestive heart failure are not entirely contradictory, and hospice care must be administered to decrease the discomfort at any phase of acute heart failure beyond the moment of diagnosis. From the beginning of the illness, congestive heart failure patients are in considerable danger of cardiovascular morbidity and mortality. The information from this source will help identify the best care practices by the palliative and hospice care team to use in treating the patient at home.
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Type of Care Delivery Model
The best care delivery model for managing a discharge plan for the patient is the Health Management Organization (HMO), whereby the physician will be at the center stage of providing care for the patient. Palliative Care Information Act is the healthcare regulation that requires physicians and other healthcare practitioners to provide terminally ill patients with information and counseling (Okumura, Sawamura & Murohara, 2018). Using this healthcare regulation, the physicians need to provide palliative care and end-of-life options to the congestive heart failure patient. Therefore, under the care delivery model, the patient has the right to access information from the physicians about the options at his disposal for the discharge plan. Significantly, the patient expresses his fears about living only six months before dying, which means that physician-assisted suicide cannot be used. Therefore, only the pain relievers will be used to help him prepare to die, which he accepts and makes his final arrangements on how his family will cope without him.
Considering that Medicare has adopted new areas such as paying for end-of-life patient counseling and hospice care, the patient will highly benefit from his current Medicare subscription (Maciver & Ross, 2018). The patient will receive medical and comfort care through a specialized team, which will help in relieving his pain and helping him to stop using aggressive treatment.
Technology
Predictive analytics in end-of-life care is digital technology that will help in improving care for the patient. The predictive data based on prediction models that will reduce unnecessary patient treatments will be applied (Okumura, Sawamura & Murohara, 2018). Therefore, the patient will be protected from unnecessary comfort during the formulation of the discharge plan.
Eliminating the unnecessary treatments from the patient’s care plan will allow the palliative and hospice care team to provide pain-relieving medicine and other alternatives that will sustain the patient throughout his remaining days without discomfort (Maciver & Ross, 2018). Therefore, the patient will have no complications that might lead to being readmitted to the hospital.
Patient Facts
A 70-year-old man was hospitalized with stage 4 congestive heart failure issues and is expected to be discharged in two days. This patient’s life expectancy is fewer than six months. The patient refuses to discuss extra resources in the house because he is in denial about his condition. A living will is not currently in place for the patient. The patient and his spouse drove 100 kilometers to the hospital since their hometown has a scarcity of healthcare professionals. A local spouse and two children are among the patient’s support networks.
To walk, the client needs aerobic respiration and a walker. According to the patient’s wife, the client is concerned about future healthcare expenses and cash. Both the doctor and the client’s wife speak Spanish as their native language, and they have a limited comprehension of English. In the previous 12 months, the patient was admitted to the hospital three times to treat congestive heart failure. Medicare covers the client.
Discharge Plan
Considering that the 70-year patient is supposed to be released in two days, there is a need to formulate a discharge plan to help him cope with his life expectancy and other issues outlined herein.
Strategic Partners
In creating the discharge plan, several stakeholders should be involved: family members, the patient’s doctor, social worker, counselor, and pharmacist. They will collaborate to align the discharge plan following healthcare professional service delivery and the culture of the patient.
Individualized Interventions
The patient will need strategies to help him gain physical comfort ...