Care Coordination Approaches and Patients Needs - Essay Example

Patient Care Plan

Introduction

Different patients require different health care, depending on the condition they are suffering from. Various factors determine the kind of care a patient will receive. Before recommending any patient care, it is essential first to understand the history of the patient. Rebecca is one of the patients with social difficulties; this needs to be considered before selecting the patient's care.

Patient assessment

Rebecca is a patient suffering from several health conditions (poor controlled DM, HTN, hypercholesterolemia, anxiety, and obesity) that have led to diabetes. The patient needs care that will help her manage diabetes and also ovaries cancer, which is at its last stage. The objectives that lead to this diagnosis are the increase in weight, unhealthy living, and abdominal pain. The organization is determined to help the patient control diabetes and have effective end-of-life care within two years. (Gammon et al., 2018). The organization is committed to achieving the patient outcome once the chemo and radiation are introduced to that patient. The patient seems to care much about her family, and this has to lead to her being unable to control her health conditions. The diagnosis has made the patient more concerned about how her family will manage without her help. The patient’s concerning might affect the outcome; therefore, the patient should be advised to first concentrate on her health more than her family. The patient needs care, but it seems hard for the family to take care of her as she has been taking care of the family all along. The family of Rebecca also seem to have financial problems through the assessment it is like the family might not be able to have home care worker due to the financial crises the family is having since Rebecca’s husband started his deli. The family must focus on the patient's health, and the family should commit itself to the well being of the patient. To determine the patient outcome, patient experience will be the best measure to look at. The conditions of the patient require experience to manage the condition.

Rebecca, even though she is the patient, might be hard for her to control or take care of her life as the current condition requires her to be taken care of (Gammon et al., 2018). It has been an issue for Rebecca for many years to take care of herself since she comes from an Orthodox family, and she chooses to play her role as a caregiver to her family. The current condition (ovaries cancer) is a condition that needs much of care, but in the case of Rebecca, she might find it hard to take care of her, or the family might seem hard to take care of her because it has been their culture that it is her who takes care of the family. Rebecca's son appears to be the better opinion for Rebecca's care, even though Rebecca seems to trust nobody for her care.

Care coordination plans and outcomes according to performance measures and professional standards

Rebecca seems to have issues with caregivers. The family seems to contribute very little to Rebecca's care, but the son seems to care about the mother; therefore, the son can help take care of the mother. It is important to involve family members when it comes to health care; this is because involving the family will improve patient care delivery. Considering the patient's response to the healthcare, the goal was not achieved. The patient was reluctant to the procedures that could help her manage the condition. The goal of introducing the patient to chemo and radiation should be repeated by ensuring the patient understands the need for this care. According to the American Cancer Society, most patients feel reluctant at first for chemo and radiation due to the fear of the unknown (Smith et al., 2016). Rebecca her resistant to radiation is due to the negative side effects the drugs caused. The patient therefore it is vital for nurses o intervene by educating he patient the importance of the procedure and also the patient should be assured that there are alternative drugs that might not affect the patient.

Collaborative interventions that address the needs of diverse populations and varied settings

Patient education; It is crucial for patients to acquire knowledge regarding healthcare. According to, Baumbusch et al. (2018) patients who have experience recover faster; therefore, in the care of Rebecca, it is vital for nurses to show the patient appreciation of her culture but try to let her understand the need for her care as this will help the patient to gain experience that will help her manage diabetes, cancer and stress. Rebecca seems to stick to her traditional way; therefore, nurses can intervene by educating her on the importance of care and how she can get the care. educating the patient will help the patient to acquire knowledge that will help the patient to manage her conditions cost effectively. Considering Rebecca's condition, she needs care; therefore, it is the role of nurses to help Rebecca see the need for care. Through education, the nurses will make the patient see the need for self-care and this will help the patient experience to improve.

Follow-ups; to reduce the issue of readmission are essential to follow-ups of the patient’s progress (Baumbusch et al., 2018). The follow up can be done through the phone. Like Rebecca, it seems that she is a busy woman, and due to this, she has minimal time to take care of herself. Making follow-ups will help Rebecca to keep track, and it will be a proper intervention as it will make her understand the importance of taking care of her. This way, the patient will gain the experience that will lead her to heal, and this will result in patient outcomes.

Diabetes, ovaries cancer and stress affects the patient outcome (Squist et al., 2018). It is important for nurses to intervene by educating the patient on the importance of self care which is crucial in achieving the patient outcome. It is the role of nurses to make the patient understand the need for care; this way, the patient will collaborate with the nurses and the patient outcome will be achieved. Rebecca all she requires is to be convinced and educated on the importance of self acre and this will help her accept to collaborate with healthcare providers.

Conclusion

Different patients have different needs. The difference in patients’ needs causes differences in care coordination approaches; it is vital to ensure that the patient is assessed before deciding the kind of care the patient will get. Several factors determine the type of care a patient can be governing like the culture. Nursing intervention can be of great help when it comes to caring; this is because it improves the patient’s experience and leads to patient outcomes.