Assignment Instructions
A good way to understand care coordination
is to think of it as the “glue” in our healthcare
system that helps patients, families, and
health care providers organize care as we
work toward shared goals. Two important
components of care coordination are mtransitional care, which links care across different msettings, and case management which focuses on assessment, planning, advocacy, and
facilitation of care. The overall goal of care
coordination is to meet patient/family health needs while promoting safe, quality care and cost-effective outcomes.
Assignment Directions
Respond thoughtfully to the directions below. While each assignment will be highly personalized, the content should demonstrate a strong foundation derived from required course readings/videos and additional resources chosen by the student. Be sure to cite the references you use when developing your responses to the questions.
Review the case study below and then address the questions below.
Module One Case Study
Ms. G is a 58-year-old grandmother with a 15-year history of Type 2 diabetes complicated by elevated blood pressure and recurrent episodes of major depression. Ms. G has a BMI of 37 and has struggled with weight control since young adulthood. On a recent visit to her primary care doctor (PCP) for progressive fatigue and other depressive symptoms, she was found to have an HbA1c of 9.7%, a blood pressure of 190/106 and PHQ-9 score suggesting major depression despite taking an SSRI. Her PCP postponed adjusting her hypoglycemic and anti-hypertensive drug doses until her depression was under better control, and referred her to the mental health center to review and update her depression treatment. Ms. G had difficulty getting an appointment at the center, and finally saw a psychiatrist she had never seen before. At the mental health center, her blood pressure was 220/124 and Ms. G complained of headache, as well as fatigue. The psychiatrist, who had received no information about Ms. G before seeing her, became alarmed about her blood pressure and headache, and sent her to the ER. The ER physician told Ms. G that her BP medicine was inadequate and that she needed new, more powerful medications. She was given prescriptions for two new anti-hypertensive medications, but it wasn’t clear to her what she was supposed to do with her current BP drugs or which doctor she should call. So she took them all.
One week later, Ms. G had a syncopal episode on arising from the commode. 911 was called and she was taken to the nearest hospital where she was found to have neurological deficits and admitted with a possible stroke. With adjustment of her medications in the hospital, her BP stabilized and the neurological deficits cleared, and she was sent home with an appointment at the mental health center to have her worsening depression managed. Once home, she became increasingly depressed, forgetful and dysfunctional. She didn’t have the energy to get herself to the mental health center. She became increasingly non-compliant with her medications and was found bedridden and hemiparetic three weeks later by her daughter who became concerned when her phone calls went unanswered. She was readmitted to the hospital with a completed stroke.
Her PCP was dismayed to hear about Ms. G’s course from her daughter. He was unaware of any of the events that followed her last visit with him, and Ms. G’s daughter was stunned and angered by his ignorance (The Commonwealth Fund, n.d., p. 1).
Reference:
The Commonwealth Fund. (n.d). Reducing care fragmentation: A toolkit for coordinating care. Toolkit_Reducing_Care_Fragmentation.pdf
Identify 3 care coordination/transition management interventions or concepts that would have assisted in a quality transition of care for the patient in the case study and explain how they intervention/concept would have promoted positive and cost-effective outcomes. Write one clear, concise paragraph for each intervention/concept.
Post your Introduction by Wednesday 11:59 PM MT.
Post your assignment by Sunday 11:59 PM MT. Thoughtfully respond to one peer.
