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What to Submit
Your collaborative care guide should be 6 to 8 pages in length (plus a cover page and references) and must be written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margin
Final Submission: Collaborative Care Guide
In Module Seven, you will submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course. This submission will be graded with the Final Project Rubric.
Prompt
Based on your analysis of the case study, develop a collaborative care guide in which you assess the client’s needs, make recommendations concerning the interdisciplinary team, and create a follow-up care plan. Remember to use healthcare terminology when appropriate.
Specifically, the following critical elements must be addressed:
Introduction
Based on an analysis of the case study, research and select the most appropriate research-based strategies to use with this client. What are the most effective strategies used with this client population? Why?
Inpatient Assessment
In a narrative format, provide an overview—using a strengths-based focus—to identify the inpatient client needs represented in the context of the case.
What are the central physiological, emotional, social, and environmental issues facing this client?
How will her strengths help her make any needed transitions?
Does trauma impact this client? How?
What potential complexities could the client encounter during her inpatient stay? How will these complexities impact the client?
What types of strategies could you employ in this setting to ensure that the client is not re-traumatized?
Develop effective strategies to address the client’s inpatient financial needs. How can you best facilitate access to recommended services?
What resources might be available in her community to fill unmet financial needs?
Are there state or federal resources available to assist this client?
The Interdisciplinary Team
Based on the case study, ideally who should serve on the interdisciplinary team tasked with developing the client’s care plan? Why?
Analyze the role of each member of the interdisciplinary team in relation to the following:
Improving patient care. For instance, you might consider the role of a team member who would have day-to-day interaction with the client throughout the client’s hospital stay.
Improving patient outcomes. For instance, you might consider the role of a team member who would be responsible for developing cost-effective outcomes.
What strategies should be implemented by the team to ensure the patient understands the terms and outcomes of the post-discharge plan?
Follow-Up Care Plan
Based on all of the client’s needs, create a comprehensive follow-up care plan. Include the following:
Applying best practices, explain the basic post-discharge client needs represented within the case study.
Develop strategies to arrange provision of services to the client.
Develop effective strategies to address the client’s post-discharge financial needs. What strategies will you use to ensure client access to recommended services?
Conclusion
Based on the case study, how would the difficulty of navigating the available resources for both inpatient and discharge needs impact the client?
What long-term effects will the strategies you developed for addressing the client’s inpatient and post-discharge financial deficits potentially have?
Describe the expected outcomes of this care plan.
Academic Reflection
Reflect on your decisions and choices in the care plan based on the forces that have influenced the U.S. healthcare system.
How has the evolution of the U.S. healthcare system positively impacted patients such as the one in this case? Negatively?
Overview
The final project for this course requires you to analyze the provided case study to identify basic client inpatient and post-discharge needs. As you will see, the analysis of this case requires awareness of trauma and recovery and the fundamentals of ongoing care for neurological disorders and resultant paralysis, as well as sensitivity to health and lifestyle issues associated with aging. Based on the identified needs, you will develop a collaborative care guide, including several essential elements. To create this guide, you will assess research findings to identify goals and evidence-based strategies to address these needs or gaps in services for both inpatient and post-discharge care. You will identify the recommendations you will make during the multidisciplinary care planning session, while being sure to address any financial deficits that are identified for the patient. In your work, you will incorporate appropriate medical terminology to enhance comprehension of care plan objectives for all stakeholders.
The project is divided into three milestones, each including elements of the final project. These milestones will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. Milestones will be submitted in Modules Three, Four, and Five. The final product will be submitted in Module Seven.
In this assignment, you will demonstrate your mastery of the following course outcomes:
Illustrate the complexity of navigating the U.S. healthcare system for addressing its impact on patients
Analyze the role of the human services worker and interdisciplinary teams for improving patient care and outcomes
Apply best practices in the creation of inpatient and discharge care plans
Develop basic strategies for addressing financial challenges faced by individual patients
Analyze the forces that have influenced the evolution of the U.S. healthcare system
Case Study
Jean is an 87-year-old woman who was admitted to Manchester Community Hospital, in Manchester, New Hampshire, after having a debilitating stroke that paralyzed the left half of her body. She is a widow, and her three adult children live in different states. She needs assistance eating, transferring to her wheelchair, and most other activities of daily living. Her medical issues related to the stroke are quickly being resolved, and it is time to begin assessing her needs for discharge and post-discharge. It is important to note that Jean’s savings have been totally depleted and her medical bills are mounting since her healthcare insurance has proven to be inadequate to cover her medical expenses. Her limited pension and social security barely covered her living expenses prior to her stroke and are unlikely to cover the escalating expenses that she will undoubtedly encounter based on her medical condition. Moreover, Jean has been clinically diagnosed with PTSD after being raped by a neighbor in her home two years ago. She is still grappling with the effects of the trauma, even as the criminal case against the perpetrator slowly moves forward. Although her family modified the home to make it more secure and less vulnerable to intrusion, her current lack of mobility is weighing heavily on her psychologically. Despite her current issues, Jean derives great comfort from her faith as a devout Catholic. She typically has a wonderful sense of humor and is highly organized, having worked as an elementary school teacher during her earlier years. She participates regularly in the local garden club and on her neighborhood welcoming committee. She has a wide circle of friends with whom she interacts. Her children are currently staying in Manchester to oversee her care and to contribute to the development of her post-discharge care plan. It is unclear whether any of the children will stay on after her discharge to help care for Jean, but this seems unlikely unless considered essential by the medical team. An interdisciplinary team is being developed to design a comprehensive plan for Jean’s post-discharge care.
