Liam is a 15 year old with a history of Juvenile idiopathic arthritis and Asthma, diagnosed at the age of 10. His primary triggers are dust and pollen grains. He also has a history of a fracture in his right wrist that occurred 3 years ago. On assessment, there is mild swelling on his right hand and shoulder and left knee. He also reports exacerbation of his asthma in the last 2-3 months and using medication every week for the same. He is also becoming increasingly socially withdrawn and his mother is concerned with his psychological status as well. He also displayed reluctance in his treatment planning as well. This case study will discuss his complex care plan and the role of a registered nurse in delivering the same.
Patient care teams, especially in primary care have the ability and the potential to improve the quality of life of patients suffering from chronic illnesses if the roles of the team members are specifically identified and their roles are specifically and clearly delegated and the team members are adequately trained for their particular role. The primary members of the care team will include the physicians-primarily involved in the provision of care. The secondary members of the care team will include the secondary care providers, who will substantiate and support the care provided by the primary providers (Boland et al., 2020).
In Liam’s case, attuned to his treatment goals- both personal and team goals of improving his adherence to medications and care plan, improving his psychological state of mind, help in fostering his independent management of diseases and response to emergency situations as well. The primary care members of the team will include- paediatrician for the management of both his condition- Asthma. A paediatrician will help in identification of local issues and routine illnesses in Liam’s case such as infections, cold etc. He will also coordinate with the rest of the team in management of JIA and Asthma as well. The next important member would be a pediatric asthma specialist who will help with his asthma triggers, develop a plan of action in case of exacerbations and help in establishing and fostering a plan of care that will help in attending school activities in case of a flare-up (Bradley et al., 2016). A paediatrician rheumatologist will help in identifying the potential flares of JIA and help in assessment and provision of the right medication for JIA (Harris et al., 2016). Another important member would be the psychologist who will help in conducting counselling sessions with Liam about his state of mind and his own concerns about his treatment. Also, he will help in the provision of emotional and social support to Liam and help in improving his adherence to treatment plan as well. He will also help Liam handle the stress of his medical conditions along with school activities and foster confidence and independence as well towards the treatment strategy.
The other secondary members would include the registered nurse, who will act as the complex care provider in the team and help in coordination of the care needs of the patient within the team, planning and assessment, support in terms of ensuring that the decided plan of treatment is carried out and proper follow up is done and providing clinical and local information to the patient as and when required. An advanced practice therapy practitioner or a physiotherapist will help in improving the physical activity levels and exercises as well. They will help with mobility exercises and help in improving sports activity as well. An occupational therapist can work with improving upper extremity exercises and motor skills if required and help improve upper body strength (Harris et al., 2016). A social worker will help in provision of any kind of emotional support to Liam and his family both in case of any personal or financial or family concerns. He/she can also help in identifying resources or specialists that Liam might need in the future as a part of his care team.
The goals of Liam’s care plan include –provision of adequate treatment for his exacerbations of Asthma and JIA, provision of psychological help to help improve his mental status, helping in increased physical activity and making Liam independent to manage his symptoms on his own with minimum intervention. This will require effective coordination and routine follow ups and adherence to regular appointments and treatment plan as well. It will also require psychotherapy and monthly case conferences as well.
The specific barriers to provision of care to Liam and achievement of his care goals will include medical and personal barriers. The socio-economic determinants of diseases such as access to care in terms of affordability and accessibility play a major role in determining the outcome of the patient goals (Adler et al., 2016).
In this case, the personal barriers include inability of Liam and his family to make it to appointments frequently and on time because of the distance between both his houses and the rural practitioner which is about 250-300 kms. It is both a system issue and a personal issue that the requisite service of doctors is not available in the rural area as it should be, that is near to the house (Vennedey et al., 2020). Also, the inability of his family to take him to the appointments by taking out the required time along with their own family responsibilities and financial constraints is a major barrier to the achievement of Liam’s care goals. He is also living in an unstable environment as per his risk calculator which becomes an important socio-economic barrier to achieving his treatment goals. He also has associated carer stress issues which also acts as a barrier as mentioned in his risk calculator.
Also, medical or organizational level factors such as lack of effective communication or coordination in terms of communicating about the next diagnostic or therapeutic steps along with discharges and referrals to another provider of care. There needs to be a specific plan for managing monthly meetings and coordination of care irrespective of the location of the patient and the doctors in order to do an effective follow-up of Liam’s condition (You et al., 2015). Switching his medical, records to an electronic system will also take time and effort. Another barrier seen or observed in Liam’s case is effective adherence to medication and treatment strategies in terms of making it to the appointments and management of poly-pharmacy as mentioned in his risk calculator as well. It is imperative that the present barriers to care are looked at and the condition be improved for both Liam and his family in order for them to be able to achieve the decide care goals.
The supposed role of the care coordinator is the one who does or carries out tasks in the following four key areas- managing the coordination of care needs, proper planning and assessment of the needs of the patient, provision of information and specialist support to the patient and required emotional and practical support as well (Hills et al., 2016). The management of care coordination will include establishing improved accessibility of the patient to care, especially required in Liam’s case and helping in dealing with the complexities and complications of having to attain care from a multitude of care providers. As in the case with Liam, the RN needs to coordinate and liaison with multiple types of care providers such as – pediatric rheumatologist, general practitioner, asthma specialist, psychologist, social worker, physiso-therapist, occupational therapist and counsellor as well along with Liam and his family as well. This requires effective communication skills and inter-personal skills as well. Planning and assessment of care for Liam will include the planning and coordination of his 2 monthly visits for the next 6 months and planning a monthly meeting-on call with all the members of the care team. It will also require making sure that the treatment is carried out effectively – for which proper counselling and support in terms of online-or electronic support should be provided by the RN to Liam and his family. It requires the RN to use her skills as an effective team player and a leader as well to achieve the required goals.
The RN also needs to inform the specialist and supportive services about the knowledge and provision of care and clinical information related to Liam’s condition to the respective doctors and also to his family as well. This will help in monitoring the effectiveness of his treatment goals and achievements. The skills of the RN in terms of working with a multi-disciplinary team and improving their coordination and team work will also be used in particularly handling Liam’s condition. Another aspect of care is the provision of emotional and practical support the patient. In this case, Liam and his family will require motivation and support from the RN and counselling and advocacy from the RN as well. The advocacy and coordination skills if the RN will be used for the same.
The various strategies that can be employed in provision of care to Liam should first of all include the use of electronic records. The conversion of Liam’s paper based medical records into electronic health records will help keep the records in one place and also help in maintaining effective and easy communication and coordination between the various health care providers present in the care team. Also, establishing ways of effective communication, such as organising a monthly meeting-online to share the plans and improve the care strategy for Liam. This will require the use of technology and internet facility along with the use of smart phone or laptop for conducting the meeting. Telemedicine and online health counselling strategies can be used for the same (Portnoy et al., 2020).
Another effective strategy and organisation that can be used in making sure that Liam is able to handle his asthma exacerbations effectively on his own is the idea of using school based telemedicine. It can help in effective management of the asthma exacerbation-if it occurs in the school premises as well (Halterman et al., 2018).
Also, consistent follow-ups and proper check-ups along with regular assessment of his symptoms will ensure proper management of the treatment and monitoring of the physical and psychological intervention methods as well. Liam’s psychological assessment and constant and frequent communication with him will help monitor how effective is the treatment strategy. Also, cognitive and behavioural strategies can be employed in Liam’s case to help improve treatment adherence and his mental state towards his heath status and condition as well. Improving peer support, after his close friend left for Sydney will also help in improving Liam’s mental state of mind and condition. Peer support will help provide emotional and social support to Liam and help in improving his mental health and condition (Sokol, 2016). It will also help in improving his treatment adherence and the development of a positive attitude towards his own health and the health care plan as well.
Also, required is help with his physical therapy and occupational therapy sessions in terms of professional support to help him improve his physical activity skills and improve upon his motor skills as well. This will help him participate in his school sports activities and not make him feel left out.
The role of a registered nurse as an effective complex care coordinator is very important and central to the provision of effective care and treatment to the patients. In the case discussed here, Liam’s case required specific interventions to be carried out by usage of specific skills by the RN in terms of communication skills, inter-personal skills, collaborative skills, leadership skills and ability to function in a multi-disciplinary team as well.
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Halterman, J. S., Fagnano, M., Tajon, R. S., Tremblay, P., Wang, H., Butz, A., & McConnochie, K. M. (2018). Effect of the School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program on asthma morbidity: a randomized clinical trial. JAMA Pediatrics, 172(3), e174938-e174938.
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You, J. J., Downar, J., Fowler, R. A., Lamontagne, F., Ma, I. W., Jayaraman, D., & Neary, J. (2015). Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Internal Medicine, 175(4), 549-556.
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