The Healthcare Practitioners Discussion Paper
The healthcare practitioners often find it challenging to attend to the elderly persons because their ageing condition makes them vulnerable to a wide range of illnesses. That means that they should always be ready to seek for continuous medical care because it means a lot for them. Such services can be provided at the healthcare facilities or home care organizations that specialize on the delivery of holistic advanced care to such patients as well as their families (Stolk, Bakx, Mulder, Timmers & Lenders 2013)The Healthcare Practitioners Discussion Paper. Harold is one of the elderly persons who have been constantly seeking for medical attention. From his medical assessment, it is obvious that the 83-year old man is in a dire need of medical attention. A though review of his medical record shows that the patient has a complex medical history.
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The complexities in the patient’s health are proven by the fact that he had been, on different occasions, diagnosed with angina and Cerebral Vascular Accident (CVA). The patient’s complex condition is also affirmed by the confirmation that he had, in the past, suffered from other diseases like ulcers, Postural hypotension, Gastro-Oesophageal Reflux Disorder (GORD), Hypertension (HTN), Hypercholesterolaemia Spinal injury, and Ischaemic heart disease (IHD). That justifies why, in the past, the patient has had numerous surgeries for Coronary artery bypass graft (CABG), Appendicectomy, Cholecystectomy, and hip replacements. Currently, the patient is under a care of a multidisciplinary team composed of speech pathologist, cardiology, physician, neurologist, and social worker because a time has come when he should be transferred from a hospital to a nursing home where he will continue receiving specialized advanced care that befits his condition and age (Tomasson, Peloquin, Mohammad, Love, Zhang, Choi & Merkel 2014)The Healthcare Practitioners Discussion Paper. The purpose of this paper is, therefore, to present a detailed analysis of Harold’s care, his care plan, and transition to a community nursing home where he should continue getting the necessary advanced care.
Harold has a complex condition. The information from his medical records proves that the patient has had multimorbid conditions that have been making life quite challenging for him. Since the time of his admission into the facility, the patient has proven that he has a combination of physical, psychological, social, and spiritual needs that must be met for his care to be holistic and complete (Bähler, Huber, Brüngger & Reich, 2015). All along, the patient has been on and off to the hospital. In the past, he has had to deal with numerous illnesses which have made it hard to cope-up with his normal life. At the same time, it has made him dependent because he can essentially not live without the support of others.
Physical Needs
The patient has physical needs that must be met because that is one of the reasons why he has been seeking for admission at the hospital. The incidents of angina and CVA, for instance, have exposed the patient to lots of physical pains. Meaning, he cannot lead a comfortable life like the rest of the people around him. Such conditions have deprived him of an opportunity to live normally because they have made it difficult for the patient to engage in activities like eating and speaking. Hence, it is upon the help providers to avail the necessary physical support to him. The first way through which this can be achieved is by providing the patient with appropriate medication (Polak, Szklo, Kronmal, Burke, Shea, Zavodni & O’Leary 2013)The Healthcare Practitioners Discussion Paper. This has actually been done because his team of providers has been giving him the drugs that he requires. However, to facilitate this, the patient should be enrolled into the Pharmaceutical Benefits Scheme (PBS) because it can enable him to get access to subsidized drugs. At the same time, he has been offered a speech therapy as well as the Percutaneous Endoscopic Gastrostomy (PEG) because his deteriorating condition cannot allow him to feed normally. Meaning, he has to be given PEG since it’s the only way through which the patient can get something to eat.
The patient also requires psychological support. As already hinted, the patient has been suffering from numerous illnesses like CVA, angina, ulcers, Postural hypotension, Gastro-Oesophageal Reflux Disorder (GORD), Hypertension (HTN), Hypercholesterolaemia Spinal injury, and Ischaemic heart disease (IHD). His current condition makes him vulnerable to physical and emotional pain. Therefore, what the medical team should do is to spare enough time for the provision of emotional support to the patient. This can be done by using the social workers and therapies to offer counseling services to the patient (Violan, Foguet-Boreu, Flores-Mateo, Salisbury, Blom, Freitag, Glynn, Muth & Valderas 2014)The Healthcare Practitioners Discussion Paper. It is upon these experts to use their skills to effectively counsel the patient and give him courage to boldly face his condition. The counseling services should, nevertheless, not be restricted to the patient alone, but extended to his wife and the rest of the family members. Each of these people has been psychologically affected by the patient’s condition (Singh, Singh, Loftus & Pardi 2014). The sufferings endured by Harold have brought stress and psychological trauma to his loved ones. Therefore, to provide a holistic care, the psychological support should be given to these people as well. It can give them confidence to accept the situation and face it without any unnecessary fears. However, for such services to be effective, they should encompass the elements of spirituality and culture. Meaning, for it to gain acceptance, it should be culturally-accommodative.
Psychological Support
Harold also requires social support because he has social needs that should be met no matter how challenging it might be. As already highlighted, the patient’s multimorbid condition has come with a series of physical and emotional needs that should be addressed. Therefore, in order to give him a moral support, the patient should not be isolated from his family members. The medical team should try everything within their capacity to include the patient’s family members in the treatment process (Spoorenberg, S.L., Uittenbroek, Middel, Kremer, Reijneveld & Wynia 2013). No matter how committed they might be the patient’s family members should create some time to accompany him at the facility, talk to him, encourage him, and give him all the physical assistance that he might need. If the patient gets such social support from the people like his wife, he will feel motivated and inspired. He will be happy and content because of the conviction that he is a dignified person who can be surrounded by his close family members at a time when he needs them most. It is for this reason that the services at the community health facilities are both individual and family-oriented. At the same time, the patient needs to be given the Aged Care Assessment (ACAT) by the Aged Care Assessment Team which is responsible for it. The assessment is needed because it will help in preparing the patient for approval for transition for a home care or any other service that suits him.
In ordinary terms, transition simply refers to change. In a health care context, transitional care is the kind of healthcare services given to a patient in different settings. When a patient is admitted to a healthcare facility such as a hospital, it reaches a time when he or she has to be discharged and relocated to another environment such as home where the treatment does not cease, but has to continue until a full recovery is attained (Shepperd, Lannin, Clemson, McCluskey, Cameron & Barras 2013). Transitional is a concept that is popular with elderly care because the elderly persons often need to be cared for in different settings such as hospital, palliative care, nursing home, community healthcare service centers and at their respective homes (Denson, Winefield & Beilby 2013)The Healthcare Practitioners Discussion Paper. Whenever such a need arises, the patient has to be discharged and transferred to the next location where the treatment continues. This is exactly what should be done to Harold because, as an elderly, his multimorbid conditions can be better improved if he is served in different settings. The patient deserved a transition because it will enable him to continue getting the quality care that he deserves. However, before the transition, the patient must be approved by ACAT.
Social Support
The transition of Harold from the hospital to his home should be effectively done to ensure that the care provision continues in a smooth and efficient manner. he should be transferred to his home Greenhaven SA 5119 where he will get a chance to continue with his recovery. Hence, in their transitional strategy plan, the healthcare providers should come up with a plan in which they must undertake to do two things: 1) provision of pre-transition care, and 2) provision of post-transition care.
Pre-transitional care is the plans that should be formulated before the actual transfer of Harold from the hospital. Here, the team should come up with a strategy on how the transfer process should be carried out. Among the activities to be conducted during this stage is the assessment of the patient’s progress, coordination of the transition process, and the education of the patient as well as his family on exactly what to do after discharge. All these activities are essential because they must be done before the actual discharge (Gonçalves?Bradley, Lannin, Clemson, Cameron & Shepperd 2016)The Healthcare Practitioners Discussion Paper. Discharge is a process that should be properly coordinated because its success determines what will happen to the patient thereafter. Post-discharge plan, on the other hand, is the activities that are undertaken after releasing the patient from the facility and relocating him home. To ensure that it is smoothly done, the practitioners must be ready work together and commit their time to providing a continuous care to the patient (Ellis, Thomlinson, Gemmill & Harris 2013). Among the activities that should be undertaken during this time is the follow-up of the patient to determine his progress, behavior changes, compliance with medication, and assessment of the level and quality of relationship between the patient, caregivers, and transitional care providers assigned to him. All these can be of great contribution towards the implementation of safe, smooth, and effective transition of Harold from the hospital to his home.
Once Harold is discharged from the hospital, he will look forward to be cared for at his home. While at home, the patient expects to continue receiving the quality care that can facilitate his recovery. However, all these might be a pie-dream if the transition process is not effectively done. The smoothness, safeness, and effectiveness of the patient’s transition process might be hindered by a number of barriers.
First, there might be a poor coordination of the discharge and transition process. As a matter of fact, transition is an activity that should be undertaken using a multidisciplinary approach. In other words, it should not be a one-man’s show, but a process that it done by involving different stakeholders such as the nurse, physicians, social workers, therapies, and transitional care specialists (Allen, Hutchinson, Brown & Livingston 2014). Each of these stakeholders must be directly be engaged in the transfer of the patient because they have important contributions to make. However, the transition process might be derailed if there is proper coordination between them. Failure to organize this team might interfere with the whole process and render it ineffective and inefficient in guaranteeing the patient the continued quality care that he needs both before and after discharge.
Transition Plan and Barriers to Smooth and Safe Transition
Secondly, there might be a problem of lack of effective communication between the healthcare providers, the patient and the caregivers. Transition can only be a success if it is supported by the patient and his caregivers. However, the process might be resisted or not properly supported by these people in certain circumstances like when they are not adequately informed about it (Bradley, Curry, Horwitz, Sipsma, Wang, Walsh, Goldmann, White, Piña & Krumholz 2013)The Healthcare Practitioners Discussion Paper. Such inefficiencies might be encountered when the there is ineffective communication between the patient, caregivers and the healthcare providers. Once they are not informed, they might not understand and appreciate the role of transition in the facilitation of the recovery of the patient.
Finally, the process of smooth transition might be derailed by the poor management of the post-discharge transitional care. Although the discharge and change of location might be done as planned, its implementation might not be as smooth as expected because of the challenges experienced thereafter. Such challenges might include the poor participation of the health practitioners in providing a continued care to the patient (Holland, Knafl & Bowles 2013). Since transition does not mean the end of health support, there might be serious problems if the medics cut their connection and refuse to follow-up the patient to confirm his progress. Should this happen, the recovery process of the patient in his new setting will be derailed because he would not manage to get the right quality of services that he requires.
Hospital re-admission refers to the subsequent visitation of the healthcare facility by the patient after the initial discharge. In Harold’s case, it might be synonymous to his admission to the hospital one more time after his transition to his home. Although re-admission might, at times, be inevitable, there are circumstances where it might be avoided. This argument applies to Harold because once he is discharged; he is expected to continue with his treatment or recovery at home which has been identified to be suitable for him at this point in time.
Harold might require re-admission into the hospital after his transition particularly if his condition deteriorates the extent that it might not be safe for him to continue staying at home. Such a drastic and unfortunate development might be caused by a number of factors. First, it might be as a result of failure of the patient to comply with the medication that had been prescribed by his medics. Besides, the problem might be caused by failure of the family to give the patient necessary support that he needs while recuperating at home. Last, but not least, Harold might require another admission at the hospital if he failed to get the necessary follow-up assistance from his medical providers. For this reason, therefore, to eliminate any chances of such unplanned re-admission, the following measures must be taken:
One, the discharge planning should be properly done right before the actual transition is done. Since discharge and transition is a process, it should be upon the responsible team to ensure that it is properly planned. The planning process should begin right before the actual discharge. The healthcare should come up with short and long-term plans on how to implement the discharge and transition (Litzelman, Inui, Griffin, Perkins, Cottingham, Schmitt-Wendholt & Ivy 2017)The Healthcare Practitioners Discussion Paper. All the stakeholders should be given enough time to adequately prepare for it. For example, before the discharge, the condition of the patient should be properly examined to ensure that it suits the discharge and relocation to another setting. If the preparation is done properly, everyone including the patient and the caregivers will get enough time to psychologically prepare for it. This can be beneficial in the long run because it will minimize the chances of any unplanned re-admissions that might occur once the patient is transferred to his home where he will be recuperating in the company of his loved ones.
Two, the patient should be provided with the community health services right from the time of his discharge and relocation from the hospital. Community health service is a type of healthcare service that is designed for individual patients as well as their family members. It can be applied as a novel strategy for Harold because it can play a significant role in minimizing the chances of unplanned re-admissions that might occur. The service can help in achieving this goal because it has highly-trained and experienced practitioners who can use their professional knowledge to provide physical, psychological, and spiritual support to the patient as well as his family members (Zhu, Hurtado & Tao 2017)The Healthcare Practitioners Discussion Paper. This is commendable because such a service is recommended to the patient and his caregivers at this point of time when they are all worried about the pains that Harold has been going through. It should, therefore, be upon the community health experts to ensure that they do an excellent job that can be relied upon to improve the conditions of the patient and eliminate any possibilities of unplanned hospital re-admissions.
Three, the patient and his caregivers (family members) should be provided with adequate education on how to handle the patient at home. Since it is the family members who will be available at all times, they need to be equipped with the skills that can enable them to provide effective support to the patient at home (Smith 2013). Hence, to ensure that this happens, the healthcare providers should empower the family members by providing them with the necessary information that they need. Meaning, they should be educated and provided with enough information regarding the patient’s illness, conditions, medication, and all the issues to do with the management of the condition (Glassou, Pedersen & Hansen 2014). The education should also address the way the family members should establish and maintain a cordial relationship with the patient as they address his psychological and social needs. However, the content of the teaching should be designed to suit the cultural, social, and economic needs of the patient because without that, he might end up being admitted to the hospital at any time.
Four and lastly, the healthcare practitioners who have been serving the patient should continue attending to him even after his transition from the hospital. It should be the responsibility of the practitioners to ensure that they do not stop their cooperation with the patient soon after discharge. What they must do, therefore, is to apply the principle of continuity which advocates for a continued to the patient even when he is at home (Shelef, Mazeh, Berger, Baruch & Barak 2015)The Healthcare Practitioners Discussion Paper. To accomplish this, the medics must follow-up the patient either by paying him a visit, sending an email or calling him to monitor his progress and acclimatize themselves with the information pertaining to compliance with the prescribed medications. Once this is properly done, the chances of hospital re-admission would be minimized since everything would be done in the right manner expected.
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Conclusion
Harold’s case is complex because, it has been confirmed that he had, in the past, suffered from other diseases like ulcers, Postural hypotension, Gastro-Oesophageal Reflux Disorder (GORD), Hypertension (HTN), Hypercholesterolaemia Spinal injury, and Ischaemic heart disease (IHD). The patient’s current condition implies that he has a combination of physical, psychological, social, and spiritual needs that must be addressed for him to receive the holistic care that he direly need. However, since h9s transition time has come, the healthcare providers must come up with an appropriate strategy to enable them smoothly and efficiently relocate him from the hospital to his home where he should continue receiving the care that he deserves. However, all this might not be smoothly done because of the numerous barriers that might stand on his way. However, to ensure that quality post-discharge care is offered, the healthcare providers must continue following-up his case, and avail the services of community care to him. This will ensure that there are no cases of unplanned hospital re-admission that might arise. The Healthcare Practitioners Discussion Paper