Assignment 2: A Case Study Of Mr. Jones Care Coordination Plan

This episode of care occurred in a community setting. Sara has a diagnosis of Alzheimer's disease. She live alone, has no children and is a diabetic. Sara does not speak English and her first language is Polish. Sara support worker developed a close relationship with Sara but said recently her dementia as gotten wrong and she sometimes does not remember who she is. Sara has cellulitis on her legs and was refusing to let the support worker change her dressing. She kept saying it was ok and she didn't want it to be changed. The student nurse and the district nurse tried reassuring Sara and explaining why it was importance to treat her leg but she just became more agitated and aggressive. The district nurse and support worker knew it was important

Providence Home Care LLC is a home health care service institution that is located in Oklahoma City, Oklahoma. This home health care agency was established in 2002. Providence Home Care LLC offers home care and private duty services. Some of the home health services include wound care, hospital prevention protocol, skilled and psychiatric nursing, monitoring chronic illness, physical, occupational, and speech therapy, patient and caregiver education, and more. Providence Home Care LLC has been awarded for being a National Top 500 Agency. This home health care facility is also the winner of the Quality Excellence Award.

Mrs Gale is a 70 year old widow and retired unskilled worker. The patient lives alone and relies on her son to provide basic care, medication and meals. Mrs Gale has a history of weight fluctuation owing to lifestyle but is currently at risk of malnutrition due to Parkinson’s disease. Mrs Gale shows signs of early dementia and suffers from poor mobility and pain caused by arthritis. Mrs Gale also has mild depression triggered by loss and has become socially isolated. All names have been changed as per the Nursing and Midwifery Council confidentiality guidelines (2008).

Mr. Mendivil was referred to the STAR CAST on January 1, 2018, by SGPRC due to his noncompliance with treatment and medical appointments. He is diagnosed with type 2 diabetes and is prescribed insulin four times a day. Nursing staff from Care Unlimited Home Health come to the house every day to check his blood sugar, check his blood pressure, and administer insulin as ordered. However, Jesus is reported to often refuse to have blood sugar checked and to have insulin shots. This noncompliant behavior to treatment poses a high risk for complications from poorly controlled diabetes.

SC received phone from Pa’s dtr starting that she spoke with provider agency Accucare regarding changing Pa’s schedule from a split shift to one shift starting at 5:00 AM and ending at 9:00 AM. SC informed DCW that she is not authorized to make any change to Pa’s care plan or schedule. DCW was furious demanding to know why she is not authorize to make changes to Pa’s care plan since Pa’s she’s Director of Care. SC explained to DCW that she is not Pa’s director of care because Pa’s is directs own care and moreover she cannot be the direct care worker and the Director of Care because both role conflict with each other. DCW stated that she is only being paid for 4 hours but is constantly assisting Pa’s managing her health and navigating services/resources,

According to Shi and Singh an accountable care organization, also known as an ACO, describes an integrated group of providers who are willing and able to take responsibility for improving the overall health status, care efficiency, and satisfaction with care for a defined population. The ACO was established by the Patient Protection and Affordable Care Act (PPACA) Section 3022 mainly to better the quality of care to beneficiaries and to save money for Medicare (Golden). The accountable care organization is voluntary for provider participation and Medicare beneficiaries still can choose treatment from any provider they wish which is beneficial. The ACO has been viewed as a potential tool for rebuilding the traditional Medicare coverage according to Medicare Payment Advisory Commission known as MedPAC (Rosenbaum). According to CMS,

If she returns home, what considerations need to be taken into account as part of her discharge plan? Using your local area, research and present the needed or preferred community resources (macro) that would be available to them. Critique the ability of these community resources to adequately meet the needs of this diverse family’s circumstances.

While researching, there were a couple grants that stood out to me. For instances, the System of Care Expansion Implementation Cooperative Agreements focuses mostly on improving "behavioral health outcomes for children and youth with serious emotional disturbances and their families" ("Implementation Cooperative..."). The goal for this grant is to aid the availability and access to mental health care and similar services for these children to help them with their emotional disturbances ("Implementation Cooperative...").

Case Managers have a challenging job, often dealing with patients, community agencies and facilitating their hospital discharge to the next level of care. They collaborate and communicate with the entire healthcare team and mostly with the patient during the hospitalization process. They act as support for all stakeholders to achieve positive patient outcomes. In this paper, I will be interviewing Ian Mopas, who is a Patient Care Coordinator at Kaiser Permanente in Redwood City about his education, work training, goals, and objectives as a Care Coordinator, and his responsibilities in his organization.

Throughout this assignment I will Identity and critique relevant policies, values, theories and evidence underpinning Integrated care teams. I will reflect on major implications identified for service users and for the role and practice of social work. I will look at a framework for anti- oppressive practice of which would inform my intervention.

Time is an adventure that humans seem to be preoccupied in for everything from when we get up in the morning, when we go to work and when we go to bed, but if you compared all the clocks and watches of the world, there’s a new atomic clock out that is so accurate that it will only lose one tiny second in a timeframe of 15 billion years!

The care provision options for a two and a half year old are, nurseries they provide full or

With new direction that healthcare is taking Change in nursing practice is eminent to deliver care to a complex population from conception to death. Representations on how to practice nursing is expected to raise and transform. This new endeavor is the road to keep patient healthy. The relationship between the patient and care giver will go past actual occurrences of malady. The focus is on delivering care that is mainly focus on the needs of the patient in a continuum. In collaboration with everyone in the care team the patient is a unique person with unique needs who from one stage to another, meaning from the hospital to rehab, from rehab to home and to the community. Care for everyone in the same fashion each time without limitation. The continuum of care framework focuses on integrating the services provided to the client, rather than on the integration of service organizations.

2.2 Describe how to manage risks associated with conflicts or dilemmas between an individual’s rights and the duty of care.

Urie Brofenbrenner is an American developmental psychologist who is best known for his Ecological Systems Theory of child development. This theory “focuses on broad, interconnected influences on human development. It proposes that we can best explain development in terms of the interactions between individuals and the environments in which they live (Mossler, 2013, Chapter 2, Section 2.6, Urie Bronfenbrenner and the Ecological Systems Theory,” para 1). While reviewing the Looking into the Past assignment I decided on the two events listed in the following pages to explain how these events and the Brofenbrenner theory affected me.