Patient-Centered care plan for Mrs. Snyder

Complete an interview of a patient, family members, and experienced health care workers. Then, develop a care coordination strategy and a care plan for the patient based on the information gathered from the interviews.

Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.

Whether designing care plans directed by patients’ needs and preferences, educating patients and their families at discharge, or doing their best to facilitate continuity of care for patients across settings and among providers, registered nurses use accredited health care standards to realize coordinated care. This assessment provides an opportunity for you to explore health care standards with respect to the quality of care, investigate opportunities and challenges in care coordination, and develop a proactive, patient-centered care plan.Patient-Centered care plan for Mrs. Snyder

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The National Strategy for Quality Improvement in Health Care (2011) focuses on improving patient care, maximizing health resources, and reducing preventable hospital readmissions. Care coordinators reduce readmissions of those suffering from chronic conditions (such as congestive heart failure, pneumonia, asthma, and diabetes) and are responsible for providing quality care in a fiscally responsible manner. While this may seem a reasonable task, shifting the way we use health care resources can be a challenge. Consequently, you must be cognizant of effective strategies for reducing preventable readmissions and understand the barriers that nurses face when coordinating care for patients with chronic illnesses.

Reference

Agency for Healthcare Research and Quality. (2011). 2011 report to Congress: National strategy for quality improvement in health care. Retrieved from https://www.ahrq.gov/workingforquality/reports/2011-annual-report.html

Library Research Guide

The resources provided here are optional. You may choose other resources to prepare for this assessment; however, you must ensure that they are appropriate, credible, and valid.

Care Coordination

Preparation

To prepare for this assessment, complete the following simulation below:

Care Coordination Scenario I

Care coordination is like a puzzle. Every patient has a unique set of medical, social, and cultural considerations. It’s up to the care coordination team to problem solve and figure out the best course of action for each patient. In this activity, the care coordinator is presented with one such “puzzle”: a patient who has specific family and religious concerns.Patient-Centered care plan for Mrs. Snyder

After completing the activity, you will be prepared to:

  • Investigate a care coordination plan of action for a complex case that involves medical, social, and cultural considerations.
  • Apply current health care standards to a care coordination scenario.

Challenge Details

Health Information System Characteristics and Needs

Rebecca Snyder, 56, is the matriarch of a traditional Orthodox Jewish family. She is the mother of five, including two teenagers at home, and the grandmother of seven. She was brought into the emergency room at St. Anthony Medical Center last week with uncontrolled diabetes and hyperglycemia. The doctors discovered other problems, and unfortunately Mrs. Snyder was diagnosed with advanced ovarian cancer.

As a part of your care coordination internship at St. Anthony Medical Center, you are assigned to Mrs. Snyder’s case. Because she is the primary caregiver in her family, she and her family are especially ill-prepared for this serious diagnosis. You will be responsible for investigating this situation and for helping Mrs. Snyder and her family get the care and support they need.

YOUR OFFICE

New Case

It looks like you have email from Denise McGladrey, your preceptor. Read the message, then review the documents below.

New case email

From: Denise McGladrey

To: The new hire (you)

Everyone is impressed with how well you’re doing as an intern! We’ve decided to assign you a more complicated case. The patient’s name is Rebecca Snyder. She’s 56 years old and was recently diagnosed with ovarian cancer and admitted to SAMC for uncontrolled diabetes and hyperglycemia. She’s medically stable enough to be released, and ready to start chemo and radiation on an out-patient basis.. However, there are some potential red flags in this case. Mrs. Snyder is the primary caregiver to her husband, children, and her elderly mother. She has not been treating her diabetes sufficiently.

First, read through Mrs. Snyder’s electronic medical record carefully. Then, you’ll want to meet with Mrs. Snyder as soon as possible.

This may be a tough case, but I know you’re up for it. Let me know if you need any help. Good luck!

Thanks,
Denise

Mrs. Snyder’s Electronic Medical Record

PATIENT INFORMATION

Patient Name: Rebecca Snyder
DOB: 04/24/1953
Address: 1375 Cadburry Lane, St. Louis Park MN 55402

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900

Insurance: Medicare
Primary Care Provider: Dr. Vereen, Vila East

Contact Permissions:
David Snyder, husband (952) 493-9302
Avi Snyder, son (952) 783-0021

PATIENT HISTORY

H&P: Mrs. Snyder is a 56 year old obese Orthodox Jewish women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia ranging from 230 to 389 for over 10 days, frequent urination, malaise, and mild abdominal discomfort, dyspnea on exertion and HTN on admission.

Family Hx.
Mother: Alive. History of HTN, DM, Dementia.
Father: Deceased. HX of MI, Colorectal CA
Sister: Alive. HX of Breast CA. s/p right mastectomy.

Meds on Adm: Metformin 1000 mg q hs., Lisinopril 20 mg QD. Prior to adm. Was prescribed anti-anxiety medication but self d/c’d without taper due to c/o fatigue.
V/S: 36.7, 102, 171/93, 24. O2 Saturations 92%. On room air.

Neuro: A&O x3. Appropriate responses, anxious. c/o daily H/A with minimal relief with NSIADS. Recent c/o blurred vision. Wears glasses.

Cardio: HRR. Tachycardic. No audible murmurs or c/o CP. EKG normal.

Respiratory: Lung sounds diminished in all fields. Sats 92% on RA. c/o dyspnea on exertion for 6 weeks. See for care at Ferndale clinic. Occasionally sleeps in reclining chair at hs. Obtain CXR.

GU: c/o frequent urination. Per pt. menses have not yet ceased. Menses irregular. Occasional vaginal bleeding duration: 1-2 days.

GI: c/o constipation and abd fullness. Abd. Tenderness on exam. + mild acites. Palpated pelvic mass. c/o tenderness.

POC: CBC, BMP, blood glucose ac/hs.
CXR, abd. Ultraound. V/S q 4 hr. Metoprolol 25 mg Q 4 hours for BP over 170/80.
Initiate insulin gtt at 2u/hr. Blood glucose check q 1 hr. Consider paracentesis.

ALLERGIES & MEDICATION

Allergies: Sulfa

Medication: #6700891
Metformin 1000 mg po q hs for diabetes
Lisinopril 20 mg po qd for hypertension
Prosac 20 mg po BID (per pt., self d/c’d due to fatigue)
Xanax 0.25 prn anxiety hypercholesterolemia.
Pravastatin 40 mg po bid for hypercholesterolemia.
Advil 1 tab qd pain

LAB

CBC:
RBC: 5.1 HCT: 38.8
HGB: 14.7
WBC: 11.1
MCV: 81
MCH: 31
PLT: 301

BMP:
Glucose: 399
BUN: 15
CR: 1.1
Sodium: 138
Potassium: 4.2
Chloride: 106
Co2: 23
Calcium: 11
Protein: 7.9
CA-125-1700 U

PRIMARY CARE NOTES

05/13/19:
Abd CT showed multiple liver mass nodules too many to count. Suspected liver metastasis
Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine.
MRI negative for spinal cord or brain lesions.
Plan of care: Gynecologic oncology consult.
CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.Patient-Centered care plan for Mrs. Snyder

05/12/19:
Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abdominal discomfort, dyspnea on exertion.

DX: Hyperglycemia, abd. distention & acites, suspected ovarian cancer
Called Dr. Hanson-GYN ONC. Consult expected for tomorrow. Suggested CA-124, HCG, AFP prior to consult.

Blood glucose 200 on insulin gtt. POC: d/c Insulin gtt. Begin 30 units of Lantis 1 x a day in am and 10 mg. of Novalog 3 times a day.

05/12/19:
Abd. ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is recommended.

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SOCIAL WORK

05/13/19:
Met with Mrs. Snyder on 05/12/19. Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

On 05/11/19 pt. was diagnosed with Ovarian Cancer. Work-up still in progress to determine stage, although it appears that Mrs. Snyder may have a Stage III or Stage IV ovarian cancer. In addition, Mrs. Snyder has uncontrolled diabetes with blood glucose levels consistently in the 200-300’s. PTA, she was on oral anti-diabetic medication. Will most likely be d/c’d on insulin ac/hs. Will need diabetic teaching, glucose monitoring and support.

Social:
Patient lives in a multi-level home with first floor set-up. Resides with husband, 2 teen age children and is primary caregiver for elderly mother with dementia. Independent in ADL’s. Able to walk household distances without AD but requires frequent rest breaks due to fatigue and SOB. Family responsibilities include child care (2 teenage boys) total physical care for elderly mother with dementia, shopping, meal preparation, cleaning, as well as managing the home and business finances. Husband available, however just opened a deli and is unable to assist with household duties.

Mrs. Snyder primary concern is the care for her mother. She has a sister that lives in Florida, but she has not stepped up the plate or offer to care for their mother. Mrs. Snyder has adult children. Her daughter may be of some help, however, she has 2 small children to care for while her spouse works full time. Her son, Avi lives nearby, but she does not believe that he would be able to manage her mothers’ care due to substance abuse issues. Plan: Continue to meet with Mrs. Snyder and discuss discharge options. Discuss case with care coordinator and primary care provider.

05/13/19:
Second visit with Mrs. Snyder to discuss new dx. of ovarian cancer Family member in the room. Patient quiet. Pt. described tx options provided by GYN/ONC. Pt. fearful of pain and discomfort of surgery and stated that she didn’t see that surgery would help her much. Is willing to learn about additional options other than surgery. Pt. became tearful when discussing the side effects of chemotherapy. “I don’t’ want to be in pain. I certainly don’t want to feel nauseous! I just want to go home! Why can’t I go home?” SW provided support and counseling. Session d/c’d after patient asked SW to leave.

CASE MANAGEMENT

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia. C/O frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion. Reviewed notes from SW and appreciate team input.

Mrs. Snyder has been newly diagnosed with Stage IV ovarian cancer. She has a large family and circle of friends but desires to manage on her own. Her primary concern is the care of her elderly mother who requires total physical care. Listened to concerns about surgery and chemotherapy. Educated patient regarding potential side effects and what to expect. Answered questions about Radiation. In Ovarian cancer, it is used means of combating pain and involves high energy rays, similar to X-Rays, delivered to affected parts of the body.

DIABETES EDUCATOR

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.Patient-Centered care plan for Mrs. Snyder

Previously on Metformin only. Will most likely be d/c on Insulin BID with SSI ac.

Met with patient to discuss dietary needs and restrictions. Mrs. Snyder keeps a kosher household. Family members are lactose intolerant, have nut allergies, and her mother needs to have her meals pureed due to cognitive difficulties that impact her nutritional status. Pt. prepares meals and shops for the family. Pt. makes traditional meals such as roast beef, kugel, and potatoes. Occasional fresh greens, but the majority of fruits and vegetables are canned. Pt. admits to snacking on popped corn salty chips and enjoys chocolate cookies at bedtime.

Plan of Care: Provided Mrs. Snyder with diabetic resources. Diabetic diet and insulin teaching. Would benefit from diabetic nutritional counselling at d/c. Diabetic teaching initiated.

REHAB

Initial-Consult: 05/13/19
Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

Lives in a multi-level house with 8 STE. One flight of steps to second level. Bed and bath on 2nd level with first floor set up available. Resides with husband, elderly mother and 2 teenage sons.

Independent in ADL’s. Requires additional time due to fatigue and recent SOB.

Household duties include: walking household distances, shopping, meal preparation, cleaning, driving, and providing total care to elderly mother, managing business and personal finances.

Pt. able to ambulate 50′ without AD, but required HHA due to c/o feeling unsteady. Required seated rest breaks x4 due to c/o SOB and fatigue. Pulse oximeter 91% with ambulation. Returned to chair with pulse oximeter to 92%. In no distress.

Bed to chair transfer: Independent
Toilet transfer: Independent.13 steps with frequent rest breaks.
Steps: Patient able to ascent/descend
LTG: Pt. will walk 200′ without AD independently.
STG: Pt. will walk 50′ without seated rest break.

PROGRESS NOTES

Given patient s/s, suspect Ovarian Cancer. Appreciate Gynecologic oncologist consult. To discuss options with patient. Surgery may be an option, however, due to her having stage IV, supportive care, pain and symptom management is more likely through chemotherapy and radiation.

GYN/ONC

Mrs. Snyder is a 56 year old Orthodox women with a PMH of poorly controlled DM, HTN, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, malaise, and mild abd. Discomfort. Her initial exam revealed and enlarged abd. with pelvic mass. GYN/ONC physical exam: palpable bilateral ovaries with size consistent with radiology.

Radiologic studies revealed:
05/12/19: Abd. Ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is recommended for comfort and disease staging.
05/12/19: Abd CT showed multiple liver mass nodules too many to count. Suspected liver metastasis
05/13/19: Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine.
05/13/19: MRI negative for spinal cord or brain lesions.

Blood work:
CA-125-1500 U/ml
human chorionic gonadotropin (HCG): 6241
alpha-fetoprotein (AFP): 997
Paracentecis lactate dehydrogenase (LDH): Above normal @ 480U/L

Based on physical presentation, blood work and radiology studies, Ovarian Cancer is confirmed. Discuss with pt. treatment options such as surgery and/or Chemotherapy and radiation. Thank you for allowing me to consult on Mrs. Snyder.

Please download the PDF for more information from The Centers for Medicare & Medicaid Services (CMS).

You now know more about Mrs. Snyder’s case and can start assessing her situation. Refer back to her electronic medical record at any time if you need more information. Now, you should meet with Mrs. Snyder and ask her some questions.Patient-Centered care plan for Mrs. Snyder

Ask Mrs. Snyder questions to find out more about her situation. You may ask her as few or as many questions as you like.

How are you feeling today, Mrs. Snyder?

Rebecca: Oy, I’ve been better, I guess! The pain medication is making me very sleepy. But it’s controlling the pain. So I guess I can stand it for now. But when I go home I’m not going to be able to be this out of it. Mostly I’m just worried sick about my family. I’m the one who takes care of everything. And I mean everything—the cooking, the cleaning, the dogs, rides to baseball practice for my sons… and my mother too. She lives with us, and I take care of her because she’s not well. I just want to go home so I can take care of everything like I’m supposed to!

Can you tell me about your family situation?

02:12

Rebecca: Well, David is my husband. We’ve been married for 36 years now! He used to be an accountant, but last year he finally took the plunge and bought his own deli. His dream come true. It’s going ok, but it’s a lot of work, and sometimes I don’t see him all day because he’s working. And we have five children. Two of them are at home—my twin boys Eli and Isaac. They’re 14 and they’re really great kids… they’re both on the baseball team and all kinds of activities, and I feel like I spend half my life driving them places. And also taking care of their dogs… oy. We never had dogs before, but the twins just begged us for years, so we got them two great big Golden Retrievers. The deal was that they were supposed to take care of the dogs, but you can imagine how that went!

Then we have three grown kids. Our oldest son Oren lives in New Jersey and we don’t see him enough. He’s married and has four children. Our daughter Devorah lives close by and I see her every day. She has two beautiful little girls and she’s a little overwhelmed, so I help her out as much as I can. And our other son, Avi… oy, he’s a handful! He has a little boy and just split up from his lovely wife, which I keep telling him is a terrible idea, but why would he listen to his mother? My husband made him the assistant manager of the deli, and that’s been an absolute disaster—especially because, well, I hope I’m not telling you too much, but he has a drinking problem. That boy needs to learn some responsibility fast. The other member of my household is my mother, who’s 87 years old and not in good health. She was doing fine on her own until a few years ago, but now the dementia is getting worse and she just can’t be alone anymore.

Is there someone at home who can help take care of you?

Rebecca: Take care of me? Now that would be a change. I mean, I don’t want to complain. We’re a very traditional family when it comes to women’s work and men’s work. And that was completely my choice. I actually wasn’t raised Orthodox. My family was somewhat observant, but not the way we are—we didn’t keep kosher growing up, and my mother worked as soon as we were in elementary school. I met David at a dance, and that was that. I married him and became Orthodox. So I chose this lifestyle and the traditional gender roles that come with it. I couldn’t imagine it any other way. So no, there’s no one who can take care of me, not really. David, he’s a good man and he’ll do what he can, but he’s been working 15-hour days lately! I’m sure my daughter can help me with medication and things like that, but she’s so busy with her kids that I don’t want to burden her. We do have neighbors and friends from our synagogue…I’m sure they’ll be sending us meals and looking in on me, just like I’ve done for lots of other people over the years.

How is your home set up? Do you have to walk up and down stairs often?

Rebecca: Outside, it’s not a problem. There’s only one step up into the house. But we do have a lot of stairs inside. David and I used to sleep in the first floor bedroom suite. But then when my mother moved in, we moved into a bedroom upstairs. She uses a walker and there’s no way we could move her into any other bedroom.

How are things going with your diabetes?

Rebecca: I know… I really need to control my diabetes better. I put on all this weight when I had the twins and I’ve been gaining and losing the same 15 pounds for years, but I just can’t seem to get it off. I run around so much, you’d think that would help… I mean, I walk those dogs twice a day most of the time! But it’s just so hard to eat right… and I know, I use food as a crutch when I get stressed out about my son Avi and stuff like that, which happens pretty much all the time! And I know it would be good for all of us to make changes in our diet, but that’s not easy. My husband is the pickiest eater and my mother can only eat certain things, and three of my kids are lactose intolerant, and now it turns out my baby granddaughter who’s at my house every day has a nut allergy! And on top of all that I need to maintain a strict kosher household. There’s too many food requirements already for me to add my diabetes to the list.

How do you feel about chemo and radiation?

Rebecca: I don’t know. To be honest, I’m worried sick about the pain and the nausea. I’m terrible with pain! With all my kids, I wasn’t going to have an epidural, but every single time I wimped out pretty much immediately. I kind of wonder if I should go back on anti-anxiety pills, because I’m really upset about this… but I’m worried those will make me really sleepy, which is why I stopped taking them.

But the thing is, my doctor says the chemo and radiation could prolong my life by a couple of years potentially. Maybe even more. I know a number of people who were supposed to die of cancer right away and they hung on for years! So that’s what I need to do, right? (tears up) My family needs me. I’m honestly more scared about what’s going to happen to my family when I’m gone. God will take care of me, but who’s going to walk the dogs?

What questions do you have for me?

Rebecca: I’m so worried about my mother. Can you… I don’t know if it’s part of what you do, but can you help me figure out what to do about her? I was determined to keep her out of a home no matter what, and I still feel that way. But what if I can’t take care of her anymore? My sister lives in Florida and I guess she could take her in, but I don’t want to send my mother so far away when we’re her main support system…and anyway, I frankly don’t think my sister has the patience to handle my mother’s health problems. It’s probably too much to ask, but if you could give me some advice about what to do for her…? This is really eating me up inside.Patient-Centered care plan for Mrs. Snyder

Family Interviews

Hopefully you have a better sense of Mrs. Snyder’s situation. She’s tired now, so now it’s time to talk to some family members to see what insight they have about how to provide Mrs. Snyder about the care she needs. You only have time for one phone call right now.

Select a family member to hear them

Calling:

Avi Snyder

Rebecca Synder’s Son

Mr. Snyder, I have some questions for you about your mother’s care.

Avi: Oh, I’m so glad you called! My father’s way too upset to talk about this right now, and frankly he doesn’t know the first thing about what my mom needs. My mother probably gave you this big spiel about what a no-goodnick son I am, didn’t she? Oh, never mind that. I know a lot more about what’s going on than my mother gives me credit. What questions do you have for me?

How is your mother feeling about her illness?

Avi: Well, you can imagine, she’s certainly not happy about it! For one thing, she’s worried sick about everyone else. She really does take care of everything in our family, and she likes it that way. On top of everything she does, she insists on taking care of my grandmother and keeping her out of a home. But she’s probably told you all of that. What she probably hasn’t told you is how scared she is about the chemo and the pain. I don’t think she’s particularly scared about death—I mean, more than any of us are—but she’s always been terrified of doctors and pain. I suspect she has a lower threshold for pain than most people. I know I do, and maybe that’s a genetic thing? Anyways, one thing my mom might not have told you is that she’s been off and on anti-anxiety meds for years, and unfortunately they make her really tired so she hasn’t been able to stay on them. And pain is one of her biggest fears. So I hope you and the doctors keep this in mind when you’re putting together a plan for her. She’s not going to tell you how anxious she is about her treatment, but believe me, she is.

Is there anyone in the family who can help care for her?

Avi: Yeah… me! She’ll kick and scream because she thinks that’s a daughter’s role and that I’m a no-goodnik. But my sister isn’t in a position to help all that much. I mean, she’ll do what she can, but… well, okay, please don’t tell my mom this yet, but my sister thinks she might be pregnant again. So she’s already got two little girls under the age of four and possibly another one on the way, and she doesn’t seem to have easy pregnancies. So if she’s actually pregnant, she’s not going to be able to help all that much, and even if she’s not pregnant, she’s already overwhelmed with parenthood. But I can help. And my little brothers can help out too. She’s always complaining that they don’t do things like walk the dogs, but that’s because she doesn’t make them. They’re 14 years old and they’re perfectly capable of cleaning up after themselves and doing some of the cooking. Also, I’m sure my mother hasn’t said anything, but she has a sister who lives in Florida who will be more than willing to fly in and help. She and my Aunt Janet don’t get along all the time and I’m sure my mom doesn’t want to burden her, but Aunt Janet is retired and has plenty of money and would be on a plane in a minute if my mom would ask.

Can you describe the situation with your grandmother living in the home?

Avi: My Baubie needs to be in a nursing home. In my opinion, that should have happened six months ago, even before my mom’s cancer diagnosis. I admire my mother for taking on the role of caregiver, but there’s a point where it’s too much. When my grandmother started needing help bathing and feeding herself, that’s when she needed to move out, in my opinion. Also, my grandmother’s wandered out the front door by herself a few times. She hasn’t gone far and she hasn’t gotten lost, but I think there’s a good possibility that could happen.

How would your mother feel about a home health aide?

Avi: Oy! She’d kick and scream and tell us she can do it all herself. But she’d probably go for it eventually. The problem with that is that I don’t know if they could afford for someone to come in. When my dad was an accountant they had better insurance. But now that my dad quit and started his own deli, they’re covered by insurance through the Affordable Care Act. And thank God that’s available! But I don’t think it covers home health care, does it? That’s something we need help figuring out. Because the deli has been a huge financial burden for the family. Huge! It’s doing pretty well, but all businesses are slow at first, and there’s just not that much money coming in. And my mom has been adamant about not tapping into my brothers’ college funds for her health care. Ugh! I really don’t know what we’re going to do. I wish my mom were old enough for Medicare, but she’s only 56.Patient-Centered care plan for Mrs. Snyder

Do you think your mother would be open to help with her diabetes and nutrition?

Avi: Good luck with that! My sister and I have been on her case for years to start eating better and she won’t listen to us. And my father is absolutely no help. He’s the pickiest eater I know and goes nuts when my mother tries to make something more healthy. He insists that she make pies and cookies even though my mom has no willpower around those things, so they’re always in the house. And now that she has cancer, I know that a healthier diet would make things a little easier for her, but I just don’t see that happening. I see my mom just throwing in the towel and saying that she’s dying anyway and she should be able to eat whatever she wants.

Is there anything else you’d like us to know about your mother’s care?

Avi: My father is having a really hard time coping with this. He’s coping by working more, which is pretty much the opposite of what should be happening. My father is completely ill-equipped to deal with this situation, both emotionally and in terms of knowing how to be a caregiver. I wonder if there’s some kind of Jewish support group we could find for him. And no one wants to talk about this, but there’s a pretty good chance he’s going to be a single father to my little brothers. I think my mother thinks that Devorah’s going to raise them, but I don’t think she can handle that, especially if it turns out she’s pregnant again. Our family needs to have a serious conversation about that, but we’re not so great at communication.

OUR OFFICE

Case Strategy

It looks like you have a new email from Denise McGladrey, your preceptor. Read the message.

Mrs. Snyder’s case

From: Denise McGladrey

To: The New Hire (you)

It looks like you’ve gathered some helpful information about Mrs. Snyder’s case! Now it’s time to come up with a care coordination strategy. At this point, you’ll want to speak with a social worker to discuss next steps. I suggest you meet with Samantha Rockwell, as she’s experienced with complicated cases like this. I also suggest that you meet with Karen Wu to discuss nutritional issues. In addition, it can be very helpful to speak with an experienced case manager, especially since this is your first complicated case.

Best of luck,
Denise

The meeting: there are 3 participants

Karen Wu             Samantha Rockwell        Nora Jackson-Green

Dietician               Social Worker                 Case Manager

  • Do you think a home health care nurse is a viable solution?

Karen: I think that’s the best solution. It definitely sounds like Mrs. Snyder doesn’t have anyone who can take care of her to the degree to she needs. She needs to have a home health nurse working with her on her diabetes and to assess her for additional problems.

Samantha: That may be the case. But it sounds like they have financial concerns.

Nora: They have insurance under the Affordable Care Act. If home health care turns out to be the best option, you’re going to need to do some research and find something that’s covered by the family’s insurance.

Karen: I know finances are a concern. But if there’s any way to make it work, this sounds like a clear-cut case where a home health care nurse is needed on a part-time basis. The fact that she’s done such a poor job taking care of her diabetes is evidence that she’s not going to be able to care for herself on her own.

  • It sounds like there may be some relatives who are able to help. To what degree should we pursue that?

Nora: According to Mrs. Snyder’s son, she has a sister in Florida who may be able to help.

Karen: But it sounds like Mrs. Snyder is reluctant to ask her sister for help.

Samantha: I agree that this sounds like a good potential option. Maybe you could discuss this more with Avi? You might suggest that he give the sister a call.Patient-Centered care plan for Mrs. Snyder

Nora: And you probably should talk more with Avi about getting family members to pitch in.

Samantha: Are you sure? It sounds like Mrs. Snyder isn’t on the best of terms with Avi. Maybe we should try to communicate again with her husband.

Nora: Maybe. But so far her husband has been very uncommunicative and seems to be in denial. Avi was very helpful on the phone. It’s possible her relationship with her son is better than what she says it is.

Samantha: Regardless of who we talk to, I think we need to find some resources to help the family out. This isn’t the first family with this problem. I recommend you contact Jewish family resources in the Minneapolis area and find out what resources they have available to help with this family.

Nora: That’s a very good idea, Samantha. And find out about possible resources through their synagogue. The family seems to be strongly affiliated with the Orthodox Jewish community in the area. It’s likely that there are informal support systems that can help the family with things like meals and housekeeping.

  • What should be done about Mrs. Snyder’s mother?

Nora: I think this has to be a priority. Mrs. Snyder is her primary caregiver, and that’s not sustainable anymore.

Karen: I agree. Mrs. Snyder needs to be able to focus on her own health care needs, including diabetes care and nutrition.

Nora: There’s also the matter of the first floor room where her mother stays. Mrs. Snyder is overweight and not in good shape. Once she’s exhausted from the chemo, those stairs are going to be a real burden.

Samantha: But she’s quite adamant about her mother staying. We can’t make her get rid of her mother.

Karen: No, but the case manager can strongly recommend this. And we can try to get other family members on board. Avi certainly agrees that it’s time for the mother to live in a facility.

Nora: If this is going to happen, we need to find a facility that the family can afford and that Mrs. Snyder feels comfortable with. And it needs to be reasonably close to their home.

Samantha: And it needs to cater to Jewish families.

  • How should we address the issue of Mrs. Snyder’s anxiety, especially in relation to pain?

Samantha: I’m so glad you’re addressing this. I’m afraid that medical providers sometimes dismiss anxious patients as problem patients.

Nora: I agree. One thing we can do is educate Mrs. Snyder about pain relief options. She needs to know that if something isn’t working, there are other drugs and other options.

Samantha: I also think she would benefit quite a bit from talking to a counselor about anxiety. Especially since she hasn’t had success with anti-anxiety drugs. Or maybe she would benefit from a support group.

Nora: Keep in mind that she has financial concerns. But I definitely agree that counseling of some sort would help her.

Karen: I also think it would be helpful to talk with her about nutrition in relation to anxiety. Obviously that’s not the only answer. But she might be able to address the anxiety in part through dietary changes—and through exercise as well.

  • What can we do to help Mrs. Snyder with diabetes and nutrition issues?

Karen: This is so important. Improving her diet and getting the diabetes under control will make her feel better. Good nutrition can help a patient feel much stronger during cancer treatment. She needs to be eating foods that are easy to digest and that are high in protein. Many cancer patients need to drink supplemental shakes to make sure they get the nutrients they need. And it may not be realistic to get her down to an ideal weight, but a moderate amount of weight loss may help her feel better and make it easier to control the diabetes.

Samantha: I think we should try to get the family on board to help. It sounds like she’s meeting resistance from her husband when she tries to cook better. That’s hard to get around in such a traditional family.

Karen: I’m wondering if it’s possible to get a dietician to come to the Snyder’s home and work with the family.

Nora: Maybe. But don’t forget that they have financial concerns.

Karen: At the very least, we need to make sure she talks to a diabetes educator before she leaves the hospital.

  • How can we help the Snyder family adapt to this situation and to the possible loss of Mrs. Snyder?Patient-Centered care plan for Mrs. Snyder 

Samantha: We really need to identify some resources for the family.

Nora: It sounds like they need help communicating with each other. Mr. Snyder sounds like he’s in denial. Nobody’s talking about things like finding a facility for the grandmother. Or what’s going to happen to the two teenage boys if their mother passes away.

Samantha: I hear you. They have so many needs that I’m not sure where to start. I guess the first thing to do would be to find out what resources are available in the Jewish community.

Nora: Cancer support groups for the husband and the kids would be a big help too. I know there are support groups available for teenagers who have parents with serious illnesses.

 

In the above simulation, you obtained the information needed to develop a care coordination strategy for Mrs. Snyder and her family. You may use an intervention developed as part of your first assessment. Locate applicable current standards and benchmarks as you determine the best way to develop this strategy.

Requirements

Develop a proactive, patient-centered care plan for the patient, using the information gained from your simulated interviews. Focus on care coordination and national care coordination initiatives.

Care Plan Format

Use the Patient Care Plan Template ] provided below;

Name:                                                                                                  Date:

Patient Identifier:                                                                                 Patient Medical Diagnosis:

Nursing Diagnosis
Assessment Data		 Goals and Outcome Nursing Interventions Rationale Outcome Evaluation
and Re-planning
Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis. Write two goal statements for each nursing diagnosis. Goals must be patient- and family-focused, measurable, attainable, reasonable, and time-specific. List at least three nursing or collaborative interventions; provide the rationale for each goal and outcome. Explain why each intervention is indicated or therapeutic; cite applicable references that support each intervention. Were the goals met? How would you revise the plan of care according the patient’s response to the current plan of care? Support your conclusions with outcome measures and professional standards.
         

 

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Care Plan

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your care plan addresses each point, at a minimum. Read the Patient Care Plan Scoring Guide to better understand how each criterion will be assessed.

  • Assess a patient’s condition from a coordinated-care perspective.
    • Consider the full scope of the patient’s needs.
    • Include 3–5 pieces of data (subjective, objective, or a combination) that led to a nursing diagnosis.
  • Develop nursing diagnoses that align with patient assessment data.Patient-Centered care plan for Mrs. Snyder
    • Write two goal statements for each diagnosis.
    • Ensure goals are patient- and family-focused, measurable, attainable, reasonable, and time-specific.
    • Consider the psychosociocultural aspect of care.
  • Determine appropriate nursing or collaborative interventions.
    • List at least three nursing or collaborative interventions.
    • Provide the rationale for each goal or outcome.
  • Explain why each intervention is indicated or therapeutic.
    • Cite applicable references that support each intervention.
  • Evaluate care coordination outcomes according to measures and standards.
    • Indicate if the goals were met. If they were not met, explain why.
    • Describe how you would revise the plan of care based on the patient’s response to the current plan.
    • Support conclusions with outcome measures and professional standards.
  • Write clearly and concisely, using correct grammar and mechanics.
    • Express your main points and conclusions coherently.
    • Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
  • Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Patient-Centered care plan for Mrs. Snyder