Health Services Coordination - Comprehensive Care Plan
COMPETENCIES
7070.19.1 : Care Coordination Solutions
The graduate develops comprehensive care coordination solutions by integrating core concepts from across the degree program.
7070.19.2 : Patient-Focused Care Coordination
The graduate recommends strategies to advance patient-focused care coordination aimed at increasing client engagement of diverse populations, decreasing readmission rates, and reducing cost of care.
7070.19.3 : Management Practices
The graduate evaluates management practices in care coordination planning and implementation to ensure ethical, legal, and regulatory compliance.
7070.19.4 : Health Information Technology
The graduate recommends health information technology strategies to ensure that care coordination practices advance healthcare outcomes.
INTRODUCTION
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.
SCENARIO
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.
REQUIREMENTS
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. The originality report that is provided when you submit your task can be used as a guide.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
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
• the source of the consult
• the reason for the consult
• the key interdisciplinary team members who were involved in the care of the client
Background
2. Describe the biopsychosocial history of the client in narrative format, including the following:
a. health history
b. behavioral health history
c. social history
d. support system
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.
RUBRIC:
A1:SBAR SITUATION:
The description of the client’s situation includes all of the given elements, contains relevant details, is comprehensive, and is written in narrative format
A2A: SBAR Background: Health History:
The description of the health history within the biopsychosocial history of the client contains relevant details, is comprehensive, and is written in narrative format.
A2B: SBAR Background: Behavioral Health History
The description of the behavioral health history within the biopsychosocial history of the client contains relevant details, is comprehensive, and is written in narrative format
A2C: SBAR Background: Social History
The description of the social history within the biopsychosocial history of the client contains relevant details, is comprehensive, and is written in narrative format
A2D: SBAR Background: Support System
The description of the support system within the biopsychosocial history of the client contains relevant details, is comprehensive, and is written in narrative format
A3A: SBAR Assessment: Models
Appropriate assessment and intervention models for the client are identified.
A3A1: SBAR Assessment: Addressing Challenges
The explanation of how 1 model identified in part A3a could be applied to address challenges and barriers to positive client outcomes includes a thorough description of how the model will appropriately address the challenges and barriers and is well supported. The client outcomes are clearly identified within the response and are positive. The explanation demonstrates a comprehensive understanding of how to apply assessment and intervention models.
A3B: SBAR Assessment: Prevention Practice
1 relevant prevention practice associated with a client risk assessment is identified and is logical and relevant to the client
A3C: SBAR Assessment: Intervention Approaches
The 2 intervention practices used to benefit the client are logical and are described in a comprehensive manner. The description focuses on the benefit to the client and is well supported
A3D: SBAR Assessment: Shared-Decision Making
Logical and relevant patterns and models of shared decision-making are identified.
A3D1: SBAR Assessment: Positive impact of Shared-Decision making
The analysis of how shared decision-making positively impacted client outcomes makes a clear, thorough, and well-supported connection between shared decision-making and the positive outcomes for the client. The analysis is focused on positive client outcomes.
A3E: SBAR Assessment: Evidence based practice (EBP)
1 aspect of the care plan that has its origins in evidence-based practice is identified. The connection between this aspect of the care plan and its origins in evidence-based practice is clear and logical.
A3E1: SBAR Assessment: EBP Implementation
The description of how the evidence-based practice was implemented in the client's care in order to improve health outcomes makes a clear and well-supported connection between the evidence-based practice from part A3e and the improvement of the client’s health outcomes. The description of how the evidence-based practice benefited the care plan is well supported, logical, and relevant to the care plan.
A4: SBAR Recommendations: Resource Referrals
The 3 identified resource referrals are distinct, relevant to the situation, and appropriate for the client
A4A: SBAR Recommendations: Client Outcomes
The description of how the resources from part A4 can improve client outcomes is relevant to the client from the care plan, is complete and thorough, addresses realistic client outcomes, and demonstrates a comprehensive understanding of how the resources can be utilized to improve client outcomes. The link between the resources and the improvement of client outcomes is strong, relevant, and realistic.
A4B: SBAR Recs: Service Barriers
The identified service barriers or barriers to resource connection are logical and appropriate to the care plan, and they demonstrate an ability to apply strategic thinking when identifying resources and evaluating for resource barriers.
A4C: SBAR Recs: Comprehensive Treatment Plan
The explanation addresses comprehensive treatment planning methods, tools, and techniques that are clearly applicable to the client in the care plan and are logically based on the location and types of services identified in the care plan. The treatment planning methods, tools, and techniques explained are comprehensive in nature and their selection demonstrates a comprehensive understanding of how to accurately engage in treatment planning
A4D: SBAR Recs: Palliative and Hospice services:
The discussion of whether or not palliative care or hospice services would be appropriate addresses the client from the care plan and is well supported and logical, discussing accurate details of the services and the qualifications for the services.
B1: Patient Centered Care Plan
The description of how the care plan from part A addresses patient-centered care is comprehensive, logically connects the care plan and patient-centered care, and incorporates accurate tenets of patient-centered care.
B2: Communication Barriers
The description of communication barriers is comprehensive. The communication barriers that are described are logical and relevant to the care plan.
B2A: Communication Strategy
The described communication strategy is reasonable and logical and could logically be implemented in the context of the care plan. The description addresses how the strategy minimized the negative impact of the communication barriers described in part B2 and is well supported
B2B: Additional Communication Strategy
The described communication strategy is reasonable and logical, and it can be logically utilized during work with clients to address communication barriers and to improve outcomes in the context of a care plan. The strategy is different from the one described in part B2a. The description demonstrates a comprehensive understanding of how to address communication barriers and improve outcomes within the context of a care plan and is well supported
B3: Developmental Stage
The discussion of 1 way in which the developmental stage of the client affected the outcomes of the case is comprehensive, logical, and relevant to the case. The outcomes addressed are logical, relevant, and clearly identified. The developmental stage logically corresponds to the age and ability of the client from the care plan.
B4: Case Components
1 thorough example for each of the given components of the case presented in the care plan is provided, and the examples are logical and relevant to the care plan.
B4A: Management Practices
The evaluation of management practices that attend to ethical, legal, and regulatory compliance needs is thorough and logical and is specific to navigating the client’s care plan. The evaluation demonstrates a comprehensive understanding of all three components.
B5: Core Values
The description of how core values and perspectives affect the care of and interactions with the client identified in the care plan is comprehensive and demonstrates a comprehensive understanding of core values and perspectives. The connection to the client and the care plan and the connection between the core values and perspectives and the care of and interactions with the client is logical and apparent.
B6: Health Information Technology Strategies
The discussion of health information technology strategies is thorough and relevant to both care coordination and the care plan. The identified health information technology strategies are logical and plausible. The focus is on the success of the care coordination and the care plan
C:APA SOURCES
The submission includes in-text citations and references for content that is quoted, paraphrased, or summarized and demonstrates a consistent application of APA style
Health Services Coordination Capstone - Comprehensive Care Plan
Student Name
Institutional Affiliation
Date
Health Services Coordination Capstone - Comprehensive Care Plan
PART 1
Situation
The setting of the situation is at AdventHealth Zephyrhills Hospital. The facility has an acute care capacity of 170 beds. It serves a diverse population of independent, young families. Mr. Watson has been diagnosed with End-stage renal disease (ESRD). The source of the consult is a request by the hospital to understand Mr. W.’s concerns about the diagnosis. The client is concerned about the escalating costs which his insurance may not cover. Mr. W. wants to know how the illness will affect his daily life. Also. Mr. W. is worried about the survival of his two daughters. Being a widower, Mr. W. worries about who can care for his children if something happens to him with renal disease. Because of such concerns, it was necessary. The reason for the consult identify Mr. W.’s needs and support his self-management, external environment stressors and manage financial obligations. In other words, it is to enable the healthcare providers to understand the problem Mr. W. faces and ensure a clear path for his treatment. It was important for Mr. W. to consult me as a healthcare coordinator so that I could get all the details concerning him. For instance, it was critical to identify the client’s background information relevant to the client's treatment.
The success of the treatment will entail the involvement of crucial interdisciplinary team members (Buljac-Samardzic, Doekhie & van Wijngaarden, 2020). The first member will be a healthcare coordinator tasked with identifying the client's needs. The coordinator will then liaise with the rest of the team members and communicate those needs. Another member will be a physician who will direct the treatment process. The physician will collaborate with the rest of the team members to ensure they follow the outlined treatment plan. Another member is an advanced practice provider. The nurse will be responsible for the day-to-day care of Mr. W. They will ensure that the patient receives the treatment as required by the physician. The other member will be a dietician. A dietician must indicate the kind of diet Mr. W. should consume, considering his current state. The member will be critical in ensuring that the client consumes meals that contain appropriate ingredients for renal patients. Additionally, a pharmacist will be needed to issue the required drugs. Lastly, a social worker would be instrumental in coordinating care once Mr. W. leaves the hospital. The social worker will assess the situation at home and make appropriate recommendations to the discharge team. Working in an interdisciplinary team would be critical
Background
The health history of Mr. W. indicates that he has been a relatively healthy individual. He does not have a history of illness in recent years. Mr. W. has remained healthy, allowing him to work as a meat manager at a local grocery store. Mr. W. has a history of cigarette smoking. However, there is no evidence to associate his smoking habit with any illness. Recently, he was diagnosed with ESRD, which has impaired his ability to work and care for his family. The behavioral health history demonstrates that Mr. W. is optimistic about getting well. He has two daughters he looks forward to caring for once he gets well. However, while smoking cigarettes cannot be associated with any particular illness at the moment, it makes Mr. W. more vulnerable to more dangerous health issues. Considering that he is dealing with ESRD, smoking could adversely affect his body and make the illness more serious. Nonetheless, Mr. W. is receptive to any advice given by healthcare professionals.
The social history of Mr. W. demonstrates that he values family. Mr. W. takes care of his two daughters after his wife passed away recently. He loves the daughters and believes they drive him to keep working and providing for them. Additionally, Mr. W. has a strong social support network. The network consists of his supportive daughters. He relies on them to get encouragement that he will pull through. The family has remained a source of strength in a difficult times. Because of the support Mr. W. receives from his family, he is optimistic that he will be well. The family has been there for him when anything is needed. The members are willing to care for him, including adhering to the physicians' directions. In addition to family members, Mr. W. enjoys the support of his friends. The friends have been instrumental in keeping him company, especially before he was admitted. The friends have come together to ensure that he has the social support he needs from them during such a time. Most importantly, the friends have been instrumental in providing the information he needs about his treatment. Further, Mr. W. has the support of church members. These have formed groups that have been praying for him. The members also take turns visiting him in the hospital. They have provided him with a critical source of spiritual nourishment during his illness.
Assessment
A relevant assessment for Mr. W is a biopsychological assessment. It is meant to understand the physical and mental well-being of the client. Through this assessment, the healthcare providers will identify the issues that affect the client adversely. The assessment will determine how Mr. W.’s loss of his wife has affected him. It will also determine the preparedness of the patient to deal with the illness. An appropriate intervention model is a patient-centered communication. According to Naughton (2018), patient-centered communication acknowledges the whole individual, including their history and social structure, aiming to develop a shared understanding of the issue and the barriers to treatment. Healthcare professionals should be competent in patient-centered communication if they are not to address their clients' needs.
Patient-centered communication would be critical in understanding Mr. W more. For the client to have positive outcomes, he needs to be engaged in the decision-making process regarding the care. The health care team needs to get the input of Mr. W. before making major decisions. The healthcare providers will enhance patient engagement in decision-making through patient-centered communication. This will improve Mr. W.s adherence to the treatment process. It will also lead to patient satisfaction care.
Because of the client risk assessment, it was possible to prevent the further deterioration of the mental wellness of the client. As indicated, Mr. W. worried about his children's future because of the illness. However, undertaking a risk assessment demonstrated the need to get the client to open up about issues affecting him. As a result, it was possible to prevent the escalation of the illness.
One intervention approach to benefit the client was enhancing communication with the providers. The client was free to ask the provider about the treatment received. Because of the open communication, the client was involved in the decision-making process. Another intervention was offering patient-centered care. The providers treated the clients with dignity and respect. Consultations were made between the providers and family members where significant decision-making was required.
Two major models of shared decision-making were employed. The first one is the SHARE Approach, a five-step process for a shared decision-making process. It entails seeking the patient's participation (Hargraves, Fournier, Montori & Bierman, 2020). Next, the provider is expected to help the patient explore and compare treatment options. Thirdly, the providers access the patient's values and preferences to determine how to customize care. The fourth step is deciding with the client. The decision is then evaluated to determine its suitability. The second model of shared decision-making is the Three Talk model. It consists of team talk where clients are meant to understand they will not be left to make tough decisions on their own (Elwyn, 2016). The patients must be assured that the providers will offer support where possible. The second aspect is option talk, where the providers offer more details regarding the available options. The last aspect is decision talk, which supports considering what is best for the client.
Shared decision-making had positive implications for Mr. W. It enabled the patient to state the kind of care he wanted. Instead of allowing the healthcare professionals to make all the decisions, the approach enabled the client to particulate in the process effectively. At the same time, it ensured t...