Comprehensive Care Plan Applying the SBAR Model
Please see attached. Please follow instructions and rubric. I provided background in the instructions.
In this task, you will create a comprehensive care plan that uses the SBAR model, as well as engage in critical thinking skills through a reflection. The comprehensive care plan highlights your applied microskills as a health service coordinator by asking you to transform a real case from your field experience into a comprehensive care plan.
Your scenario for this task should come from an actual case you encountered during your field experience. Client information should be de-identified. Use the details in the requirements and the rubric to identify an appropriate client situation. At minimum, this should be a client with whom you conducted a biopsychosocial history; engaged in assessment, intervention, and evidence-based practice; and provided resources.
A. Create a comprehensive care plan using an actual case from your field experience and applying the SBAR model by doing the following:
Situation
1. Describe the client situation in narrative format, including the following:
• the setting MEDICAL CLINIC ON BASE
• the source of the consult REFERRAL TO PHYSICAL THERAPY
• the reason for the consult LOW BACK PAIN FROM INJURY, NOT HAVING PROPER FORM FOR WEIGHT LIFTING
• the key interdisciplinary team members who were involved in the care of the client MYSELF, PHYSICIAN ASSISTANT
Background
2. Describe the biopsychosocial history of the client in narrative format, including the following:
a. health history: FRACTURED RIGHT ANKLE, VARIOUS COLDS
b. behavioral health history NONE
c. social history MARRIED, NO CHILDREN, NO ALCOHOL, NO ILLICIT DRUG USE, PREPARING FOR A PHYSIQUE COMPETITION
d. support system HUSBAND, MOTHER, FATHER, PHYSIQUE COACH
Assessment
3. Identify the client’s needs, goals, and anticipated outcomes by doing the following:
a. Identify relevant assessment and intervention models for the client.
i. Explain how one model identified in part A3a could be applied to address challenges and barriers to positive client outcomes.
b. Identify one prevention practice associated with the client risk assessment.
c. Describe two intervention approaches used to benefit the client.
d. Identify patterns and models of shared decision-making.
i. Analyze how shared decision-making positively impacted client outcomes.
e. Identify one aspect of your care plan that has its origins in evidence-based practice.
i. Describe how the evidence-based practice was implemented in the client's care in order to improve health outcomes, including how the evidence-based practice benefited the care plan.
Recommendations/Plan
4. Identify three resource referrals that are appropriate for the client.
a. Describe how the resources identified in part A4 can improve client outcomes.
b. Identify service barriers or barriers to resource connection.
c. Explain comprehensive treatment planning methods, tools, and techniques applicable to this client based on the location and types of services identified.
d. Discuss whether or not palliative care or hospice services would be appropriate for the client based on qualifications for these services.
B. Write a reflection of your care plan by doing the following:
1. Describe how the care plan addresses patient-centered care.
2. Describe communication barriers faced when working with the client from the care plan.
a. Describe one communication strategy that was implemented to minimize the negative impact of the communication barriers described in part B2.
b. Describe one additional communication strategy that can be utilized during work with clients to address communication barriers and improve client outcomes.
3. Discuss one way in which the developmental stage of the client affected the outcomes of the case presented in the care plan.
4. Identify one example for each of the following components of the case presented in the care plan:
• ethical
• legal
• regulatory compliance
a. Evaluate management practices that attend to ethical, legal, and regulatory compliance needs with regard to navigating the client’s care plan.
5. Describe how core values and perspectives affect the care of and interactions with the client identified in the care plan.
6. Discuss health information technology strategies that contributed to the success of the care coordination and the care plan.
C. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
D. Demonstrate professional communication in the content and presentation of your submission.
Comprehensive Care Plan
Name
Department, Institution Affiliation
Course Code; Course Name
Instructor’s Name
Date
Comprehensive Care Plan
Situation
The client’s situation is based on actual engagement with a female client. The setting was a medical clinic on base. The source of the consult was a referral to physical therapy. The reason for the consultation was due to low back pain. Besides, the client did not have the proper form for weight lifting. Due to the client’s condition, the interdisciplinary team members involved in providing client care are the physician assistant and me.
Background
Health History
The client showed specific health histories linked to her primary condition. The client had a fractured right ankle that she experienced during physical activities while she was young. Besides, the client also suffers from various colds, which jeopardizes her overall health conditions. The identified health history has been persistent, thus impacting the client’s physical health.
Behavioral Health History
The client did not show any significant behavioral health history. However, the major issue that the client provided is fear of consistent physical injuries. The client claimed that she was not very sure of the outcomes of the fractures once she got old, and she feared the fractures would impact her physical mobility.
Social History
The client’s social history is effective and does not negatively impact her health. She is newly married and does not have any children. However, she has a peaceful relationship with her husband. The client is not exposed to antisocial behavior such as illicit drug exposure or alcoholism. Besides, the client is preparing for physique competition which would also improve her social health. Therefore, the client’s social history is securely based on the provided evidence.
Support System
The client enjoys adequate support from different groups. She enjoys adequate social support from her husband regardless of her current condition. The husband is always with her and offers any social help and advice. The client also enjoys support from her mother and father. Lastly, the physique coach provides her with adequate advice to sustain her physical activeness. Therefore, the client enjoys an adequate support system with all the group.
Assessment
Relevant Assessment and Intervention Models
The key assessments and intervention models relevant to the client’s conditions include lumbar spine assessment, limited neurologic testing, motor and reflexes assessment, and range of motion model. The identified assessments are relevant since they determine the severity of acute low back pain.
Among the provided models, the lumbar assessment mode is the most effective for addressing the challenges and barriers to promoting positive outcomes. A full lumbar assessment would help the physical therapist relate the patient’s condition and injuries and devise an effective strategy for resolving her condition. The model focuses on all the patient’s back and identifies the severity of the back pain (Levin et al., 2018). The client outcome, which would result from the assessment, includes reduced back pain and stable physical health. Therefore, it would promote the positive outcome of the patients and address any relevant barriers.
Prevention Practice
The key prevention practice relevant to the client is reducing heavy loads. Based on the risk assessment, the client is not adequately stable due to the injuries she experienced. Avoiding heavy load would limit the client from restraining, which would make her easily recover. Therefore, the client should carry moderate weights which won’t put more pressure on her back to prevent more pain and injuries.
Intervention Approaches
The first intervention approach is consistent exercising. The client should undergo regular exercise to restore her physical condition. The key benefits of regular exercise to the client include relieving the pressured bone and adapting the lower back to normal pressure, reducing pain. According to Buchbinder et al. (2018), aerobic exercises such as biking, swimming, and walking reduce back pain and restore the client’s physical condition. Therefore, the client’s engagement in aerobic exercise would strengthen blood vessels, heart, and lungs, limiting physical health challenges.
The second intervention is medication. Medication is effective since it has a short-term effect and would successfully relieve the patient from immediate pain. The key medications that would benefit the patient include Motrin IB and Advil. The identified medications are appropriate since they prevent inflammation and reduce low back pain within a short period (Buchbinder et al., 2018). The medications should be combined with regular exercises to ensure positive benefits such as physical activeness and reduced pain. Therefore, the two intervention approaches effectively improve the client’s physical health.
Patterns and Models of Shared-decision Making
The major shared decision-making model is a three-talk model. It is a model which focuses on different conversational phases. The first phase involves initiation, which comprises offering adequate support and introducing alternatives before making an effective decision. The second phase involves comparing the relevant tradeoff and involving the client and the expert in discussing the tradeoffs (Buchbinder et al., 2018). The last phase of the model is deliberation, which is conducted depending on the informed preferences. Helman’s fork model is the second model for shared decision-making. It involves answering specific questions that the patient outlines. It leads to shared decision-making since whenever the health experts answer all the questions, there is effective collaboration and understanding, leading to rational decisions.
The shared decision-making impacted the client positively. There was a need to focus on effective strategies that would benefit the client positively. For instance, after providing the key alternatives to the client on physical activeness, the client agreed to focus on regular exercising and specific medication, which reduced her pain. Shared decision-making also allowed the patient to appreciate different elements of physical therapy after providing key alternatives and aligning to patient conditions. Therefore, shared decision-making made it easy to work with the client and successfully focus on rational decision-making.
The aspect of the Care plan
The main aspect of the care plan that has its origin in evidence-based practice is the management of client conditions through embracing psychosocia...