Patient’s History

Patient’s History

Care coordination is an individual and family-centered collaboration activity premeditated to gauge and meet the requests of a patient while helping them navigate successfully and economically through the clinical system. It emphasizes on improvement and joint services to connect patients to clinical services. Care coordination primarily helps in managing patients with chronic illness, which affects their identity and social life; thus, the need for family, friends, and a multidisciplinary occupation to solve health problems. Patients are suffering from COPD present various challenges that call for more than clinical and pharmaceutical interventions (López‐Campos, Tan, & Soriano, 2016). Care coordination helps these patients and ensures that they get options to quality healthcare in settings like a home. By collaborating with friends, family, and health professionals, patients’ needs can easily be met, and universal and respiratory difficulties solved. The best practices for COPD coordination, therefore, include pulmonary physiotherapy, integration of care, and addition to the caring transition to care models. It is only through these approaches that the needs of these patients can be met.

Patient’s History

As individuals age, they may experience physical or cognitive challenges which may call for situation in a home or nursing center. Due to these challenges, there is a need to plan the coordination activities. Destiny is a fifty-seven-year-old middle-aged woman with COPD. Even though she has been admitted to the hospital four times this year for COPD lately this week, she continues to smoke. Even after the doctor prescribing the best medication, Destiny needs oxygen immediately. She finds it challenging to take controller prescriptions when she feels better, which will be a challenge for her to use oxygen on such days. The patient does light work, has social security income, owns a beautiful home, and has Medicare policy. The seriousness of the illness confirmed during her last visit indicated that the condition would get more complicated. There was, therefore, the need to discuss with her family members to offer more help to Destiny, including making decisions and reminding her to take the prescribed medicine.

Ethical, cultural and Psychological Considerations

COPD is a progressive illness characterized by frequent episodes of respiratory breakdown. In such cases, ethical dilemmas arise concerning the best practices. Therefore, there is the need for Destiny to come up with the suitable living will and a long-lasting power of attorney for healthcare that can direct end of life decision-making in the event of late-stage COPD because these decisions are challenging to physicians. It was, therefore, ethically essential to work in the best interest of Destiny by communicating her requests in advance and making sure that this information is useful in giving safe, suitable, and successful care. She settled for pulmonary physiotherapy and incorporated care. It is necessary to ensure confidentiality and respect the best practices that Destiny chose. Cultural challenges in the community, such as the gender of the caregiver and other requirements in the city, affect patient care. It is, therefore, vital to get cultural training and come up with competent training services. Destiny wanted to have access to her medical records to tailor community resources to her needs. Destiny is psychologically affected because she was afraid of instances of failing to communicate in events of emergency and worries about the side effects of the medication.

Assumptions and Uncertainties

This preliminary care coordination plan was founded on the assumption that Destiny’s rehabilitation will take place in the community, mainly the patient’s home. The goals of the rehabilitation process will depend on issues like ethical considerations, cultural and psychological problems, behaviors, and recovery progress of the patient. Besides, the preliminary interview with the patient offered the needed information regarding the patient’s health history and background information. The main challenge was the inability of the patient to decide on the best practices to use and setting both short term and long-term goals.

Best Practices for Health Improvement

Pulmonary Rehabilitation

Pulmonary therapy involves exercising, training, and behavioral techniques that improve the lung operation of patients with COPD and guarantees the value of life. Destiny chose this practice because, through it, she will reach and retain her utmost level of autonomy and performance (Puhan et al., 2016). For this course to thrive, there is the need to involve a respiratory and physical psychotherapist, caregiver, a practitioner, a community worker, and a dietician working as a panel to manage multiple therapeutic services (Nici, & ZuWallack, 2018). This program is, therefore, essential in improving Destiny’s quality of life by minimizing shortness of breath, promoting a sense of wellbeing, and decreasing the number of times that she will be hospitalized.

Integrated Care

Notably, health professionals can improve the treatment of COPD by moving away from conceptual and systemic deficiencies of care models that only addresses emergency episodes that can lead to death. It is, therefore, important to note other illnesses that might affect the patient with COPD. Destiny chose integrated care because it deals with therapeutic, communal, emotional, and cognitive needs. This practice also treats the signs and disabilities from this disease, its general manifestations, and frequently comorbid conditions (Nici, & ZuWallack, 2018). It involves techniques aimed at ending smoking, encouraging standard exercises, optimizing therapy, collective self-management, and home care. It is, therefore, crucial for health professionals to collaborate with the patient’s family and community, which offer resources to support these patients.

Health Priorities

Patients with complicated COPD can progressively lose weight resulting in weak respiratory muscles. It is, therefore, necessary for these patients to improve their nutrition to restore these muscles. In this case, Destiny opted for learning and dietary intervention as components of the care plan that seeks to attain a healthy nutritional significance through natural diets and enhancements (Anderson, 2019). Destiny, therefore, decided to improve her lung function by ensuring a high intake of vitamins C and other antioxidants found in fruits, vegetables, and fish.

Community Resources Available

Altering the standard strategy and daily schedule of clinical exercise can be devastating even when it is clear that these adjustments will enhance the quality of patients’ care and competence of the caregiver. Luckily, there are assets in the community accessible for those interested in preliminary care coordination. Destiny identified the following resources in the city for continuum care to support the caregiver, dietician, therapist, and family members: respite care, transport services, diet providers, and physiotherapy services.

Respite Care Services

Respite care services are essential in helping ill patients to recover when the nurse, therapists, and other caregivers are on break (Philip et al., 2018). Destiny chose respite services, which were presented to match her plans. Social workers were willing to offer in-home services on regular services at the comfort of her home. It was decided that these services would last for a few hours and sometimes overnight to enable Destiny to remain at home while she continues to receive care. The social workers will have the responsibility of helping with daily life skills such as bathing, dressing, and feeding Destiny.

Rehabilitation Services

The availability of continuum care in the community is essential because it directly affects the patient’s quality of care. Community continuum care by a specialized nurse during episodes of COPD will improve the quality of life of Destiny. These rehabilitation services may include lower extremity training, like walking tests (Nici, & ZuWallack, 2018).The skilled nurse will help Destiny through her exercises to ensure that there is a minimal shortage of breath.

Transportation Services

Patients with severe COPD can travel. However, there is a need to have additional preparations and transport services because some patients cannot drive themselves. Transport services in the community can help patients like Destiny get to where they need to safe smoothly and efficiently. This will make it easier for Destiny to access various services and programs in the community

Nutrition Providers

COPD patients need to plan and have balanced diets to manage their health (Anderson, 2019). This means embracing new eating habits. Nutrition provider services in the community identified by Destiny have registered dieticians that can provide guidance, tailor education information, and help Destiny create and follow a personal action plan. Through this action plan, Destiny can identify ways of getting a balanced diet to her home during care.

Payment to Physicians

Programs that serve patients with chronic diseases pay physicians to take part in care coordination activities. The payments made are usually for reimbursing caregivers for extra time and capital. Destiny enrolled in a managed plan and thus used Medicare as an insurance method (Nici & ZuWallack, 2018). Her caregivers and team members will be paid on a full and partial basis, and through shares savings that arise from avoided readmissions to the hospital. Since Destiny had the highest number of diagnoses, her payments will increase proportionately.

Conclusion

Care coordination is essential in helping to manage patients with chronic illness, which affects their identity and social life; thus, the need for family, friends, and a multidisciplinary profession to solve health problems. When designing a preliminary care coordination plan, it is essential to consider ethical, psychological, and cultural issues in the community that can affect the continuum of care. It is also necessary to come up with the best practices and health priorities that can help minimize complications. These practices include integrated care, rehabilitation, and changing eating habits. Tailoring the resources available in the community to meet the needs of patients is essential.