NURSING 4223 Transition care;Assignmnet Graded 100 %

Clinical Simulations Reflection Name: Overview: Assignment 7 Case Management - Transitions of Care: Primary Care Clinic Objectives • Identify the role of the community health/public health nurse in the case management of populations at risk for, or experiencing, chronic illness. • Utilize communication strategies necessary for motivational interviewing. • Apply principles of case management to various clients experiencing chronic illnesses. • Demonstrate interprofessional collaboration skills in the context of case management. Competency: 1. Utilizes basic epidemiological (the incidence, distribution, and control of disease in a population) principles in public health nursing practice. 2. Utilizes collaboration to achieve public health goals. 3. Practices within the auspices of the Nurse Practice Act. 4. Establishes and maintains caring relationships with communities, systems, individuals, and families. Video Simulations: • Review the simulation. • While watching put yourself in the nurses role. • Consider how you would respond. Assignment: Complete the social determinants of health assessment form and the template below. Space will expand as you enter your responses. Be sure to address each prompt and component of each item comprehensively. Simulation Assignment Template and Rubric Item Response Possible Points Complete the assessment for social determinants of health below. 20 Based on your assessment, write a plan of care for interventions the case manager should take to address what you see as 3 critical issues significant enough to cause a barrier to this patient’s health care. Provide at least one intervention for each issue. (10 points each, total 30 points) Provide your rationale, one for each issue, for why you selected each issue. (5 points each, total 15 points) plan of care for interventions the case manager should take to address what you see as 3 critical issues significant enough to cause a barrier to this patient’s health care. Plan of care for my patient in this scenario is the patient with PTSD, COPD and Hx of smoking .This will include provision of stable housing , assisting with finances for co pay and prescription medications , and providing reliable means for transportation to attend appointments Some of the barriers to the patient’s health include Lack of stable housing Being homeless or rather not having a stable residence I associated with poor health outcomes Intervention Develop resources with state government , local leaders, and community partners e.g. churches to provide stable housing for the patients Rationale Housing will help provide safe environment free from hazards that might affect an individual’s health e.g. the patient who has COPD and is homeless is at a higher risk for developing lung complications because of sleeping in the cold Lack of finances for prescription meds / co pay Inability to afford medications or co pay means , no medications. As a result of this ,treatment plan will not be achieved especially when pharmacology interventions are needed Intervention Provide health care that is free for those without insurance. Provide resources that can help provide financial aid for purchase of medications Rationale Resources that can provide free medical care will cater for the needs of those without insurance E.g. there are church organizations that provide free health during certain times such as dental care / eye care and general health care within the community. It is therefore important to avail these resources to patients who need these Inadequate transportation Lack of transportation results in failure to attend appointments or the means to make it to the hospital when one is ill .E.g. the patient who had PTSD , had no transportation means to make it to the nearest hospital despite his complication s such as COPD Intervention 45 Help with getting rides to the clinic in order not to miss appointments /Provide vouchers that can be used for public transportation Rationale When there is no means of transport to go to the the clinic or hospital , this will interfere with meeting medical needs . Provision or transportation can help them attend appointments on time as well as not miss appointments or follow-ups Reliable transport will it can also help them go to the store to buy healthy food, since some of them don’t go to the store due to lack of transportation and instead they buy fast food within their location which is not good for their health Discuss Information Technology that could facilitate transitions of care. Information Technology that could facilitate transitions of care It enables physicians and nurses who are working closely with their patients to provide higher-quality care at lower cost Information technology provides a faster means for keying in patients inform which is time saving It also makes it easier to retrieve manage and sharing patient information between different health care workers and units Information technology provides safe means for storing patient information instead of keeping the information on paper because there is log in information needed before accessing patient’s information It facilitates care by providing better means of keeping information for longer time which cannot be done using with paper Health care personnel can work remotely using information technology and still provide effective care to patients 5 Discuss how what you learned and experienced could impact the way you deliver care to your patients in the hospital and why. In this V sim I learned that when caring for patients with medical and psychiatry issue it is important to note that , they tend to fail to take their medications as ordered . This will impact on how I deliver care to my patients by me referring them to a case manager who can help bridge the gap with the various health care professionals with whom they interact with. I will also reinforce teaching on importance of taking medications as ordered to prevent further complications I also learned that most people who are homeless or proper housing with lack of social amenities, are at a higher risk of not adhering to the requirements laid down to be followed e.g. those on oxygen may not have housing that is appropriate for oxygen use and therefore as a nurse when I deliver care to this kind of patients by reaching out to the social worker can help find a residence that is appropriate for those on oxygen or other respiratory complications I will also provide written teaching instructions to my patients and on how to take care of themselves and provide them with resources that can help them access to healthy food and means of transport in order for them not to miss appointments and also encourage them to call if they don’t understand instructions In addition, I will make a follow up to make sure I carry out evaluations on the care provided and revising them if goals are not 10 met What are your thoughts and ideas for potential solutions to the disparities that exist in this area of health-related outcomes in the United States? The following potential solutions can help solve disparities that exist in health care Addressing the rising health care costs and lack of insurance. The rising costs increases the number of uninsured people and this reduces access to high-quality care. Providing affordable health care is one way to help address health disparities Training and hiring enough health care providers/ nurses who have expertise to work with health disparity populations. Nurses / Providers need to know the type of patients they are caring for; they need to understand, if not be a part of, these communities Coordinating care between all professionals so the patients does not have to keep going to the hospital instead have different professionals see them at once without frequently having to go to hospital back and forth to see them which discourages them from attending appointments Addressing economic, social, cultural, and geographic barriers to health care in order to expand access to health services is an important step toward reducing health disparities Increasing the knowledge base on causes and interventions on various diseases /illness can help to reduce disparities Introducing uniform permeance measurement in health care by developing appropriate measurement tools. Particularly federal health programs should develop and implement a uniform set of performance measures so that patients, consumers, and providers can make informed, evidence-based decisions about health care. 20 Total 100 Social Determinants of Health Assessment Form Identify situations where there appears to be a deficiency significant enough to cause a barrier to this patient’s health care. Please add additional comments that would be helpful for outreach purposes. Yes/No or NA if unknown Comments Family Dynamics/Support Services Living alone with 2 or more chronic conditions Yes Having more chronic conditions increases the risks for complications. This patient has chronic conditions such COPD, Anxiety, depression making which can cause barrier to his overall health Living alone with significant fall risk N/A Inadequate supportive care to meet patient’s needs Yes Lack of adequate supportive care can lead to stress /depression Inadequate support plan that can progress with a decline in health Yes Lack of proper support plan e.g. when one’s health is declining will make their health get worse because this will not help in improving their health Primary Caregiver Yes A primary care giver is important especially for diseases that require someone to help care for you e.g. if one is bed ridden . This pt has no primary care giver Power of Attorney N/A Other Caregivers N/A Access to Care Inadequate transportation for medical needs Yes Patient states he does not have means of transport to use in order to go for appointments Inadequate finances to cover co-pays for appointments/prescriptions Yes No insurance and no finances to buy prescription meds or co pays Trouble navigating the complexities of health care system (i.e. knowing which provider to see; dealing with claims) Yes He has no idea which provider or specialist to see Home Environment Lack of stable housing Yes Lives in a homeless shelter and sometimes with friends Lack of cleanliness Yes Lack of stable housing and being homeless means lack clean environment Excessive clutter N/A Home infestation (bed bugs, rodents, fleas, roaches, etc) N/A Lack of running water/plumbing yes Living on the streets or being homeless , there is no guarantee for running water Lack of electricity N/A Living on the streets or being homeless , there is no guarantee for electricity Lack of heating yes Living on the streets or being homeless , there is no heating Lack of air conditioning yes Living on the streets or being homeless , there is no air conditioning Inadequate food quality Yes Patient is unable to afford healthy food because of lack of finance Substance abuse in home environment Yes Verbalizes involvement in smoking for along time Uses assistive device (specifiy walker, wheelchair, Hoyer lift, hospital bed, O2, other) Yes Oxygen Inadequate home environment for medical needs Yes Being homeless contributes to poor environment that cannot meet health needs Mental health challenges in the home environment yes Patient has PTSD and depression Does not feel save in home community N/A Personal Inadequate coping skills yes Verbalizes having PTSD and depression Inadequate organization skills N/A Inadequate compliance yes Does not take meds as ordered. Fails to attend appointment Language barriers (English as a second language) N/A Work setting difficulties (inability to leave work for appointments) N/A Recent loss of significant person in patient’s life yes Patient had lost his wife Barriers to Medical Adherence Are there barriers to medication adherence Cannot afford medications Does not understand instructions Prefers not to take Cannot swallow/administer Other Yes Does not understand instructions on how to take medications Cannot afford medications Sates his friends told him quitting smoking is hard so he is not sure if he can quit Does patient understand why they are taking their medication No He is on oxygen but still smoking and has COPD .He doesn’t seem to understand why it is important not to smoke with COPD and oxygen in use Readiness to Change Is patient engaged in changing process? Yes Verbalizes he wants to stop smoking and is ready to meet up with case manager If yes, where are they in readiness to change Precontemplation Contemplation Preparation Action Maintenance yes There was precontemplation by patient when he was put on oxygen to quit smoking . After education , verbalizes he is ready to quit smoking because his lungs were getting damaged and he was putting himself at more risk by smoking while on oxygen Challenges to Engagement yes It took a while to convince the patient to quit smoking .He said his friends influenced him not to quit because they said quitting smoking is difficult Other Was a referral made to APS NO Other barriers to this patient’s care N/A Comments: