In disease case management, the complexity of a geriatric patient’s health conditions, polypharmacy, and psychosocial needs often require expertise and guidance that is outside of a Registered Nurse (R.N.) case manager’s scope of practice and experience. Optum’s goal for members is to provide “integrated care solutions and interventions that help people manage their illnesses and lead healthier lives” (Tackling The Biggest Challenges In Health Care, n.d.). To assist the Optum R.N. case manager provide holistic and timely care for members with complicated health concerns, a weekly WebEx meeting will occur to provide a forum for the case manager to collaborate with an Interdisciplinary team of experts to gain a better understanding of the member’s …show more content…
case manager is dealing with an older adult’s complicated health situation, the collaboration with an Interdisciplinary team becomes necessary (Nancarrow, Booth, Ariss, Smith, Enderby, & Roots, 2013). During the meeting, the case manager will collaborate with the Interdisciplinary team to discuss the member’s health situation and challenges. As suggested by Nancarrow et. al (2013), the Interdisciplinary team should consist of a an appropriate skill mix of professionals. Our team will include a Medical Director, a Social Worker, a Pharmacist, a Registered Dietitian, a Behavioral Health provider, and a Certified Diabetes Educator (CDE). Other case managers in the program will attend. These Interdisciplinary conferences will offer the opportunity for all participants to engage in shared discussions and learn evidenced based standards of care and interventions to encourage current and future …show more content…
Implementation and Evaluation My role on the Interdisciplinary team will be to serve as the primary leader and participate as the CDE. Cases will be submitted to the Interdisciplinary team for review prior to the meeting. I will update the case document during the conference and when progress is reported and will submit a summary to leadership on the member’s progress towards health outcome goals. Conclusion When the complexity of a member’s co-morbidities and psychosocial circumstances are outside of the R.N. case manager’s scope of practice, it is crucial that the case manager has access to a team of experts to provide insight and interventions. To provide assistance, a weekly Interdisciplinary team conference will be held to share knowledge and determine specific solutions and interventions for the case managers to pursue with their members. Everyone who participates in the Interdisciplinary team meetings will benefit by increasing their professional knowledge on disease management and gaining a greater understanding of interventions to offer for challenging member situations. Our ultimate goal for case management will be realized when those members interacting with R.N. case managers are able to manage their conditions more effectively, resulting in improved health outcomes, reduced healthcare spending by members, and decreased program costs for our
The New England Journal of Medecine. A Controlled Trial of Inpatient and Outpatient Geriatric Evaluation and Management, 346, 905-912. Retrieved on November 8th, 2006 from http://content.nejm.org/cgi/content/full/346/12/905
...low CABG surgery, and contribute to a risk-adjusted mortality rate of 2% (Ferguson, 2012). Many of these problems do have treatments, but would require teamwork between nurses and other health care professionals to implement. Teamwork can also help to reduce risks that would arise from interventions that are undertaken without informing other health care professionals providing care to a given patient, which could result in issues such as medication interactions, patient confusion, and reduced treatment compliance (Swallow, Nightingale, Williams, Lambert, Webb, Smith, & … Allen, 2013). A QSEN project based on establishing inter would help generate process and policy improvements in an institution, which would be focused on delivering post-CABG care via interdisciplinary teams. These teams would most likely contribute to improved patient and organizational outcomes.
According to the article “Medicare Made Clear” published by United Health, “the Medicare program helps 43 million Americans get the health care they need.” The large number of Americans being helped by Medicare shows that it is important and very much needed. Being knowledgeable on the topic of Medicare and Medicaid and knowing the different aspects of the programs will be useful for many Americans.
This definition provides a goal for teams to strive for and outlines the important outcomes of high quality interprofessional collaboration. Highlighted in this definition is the need for participation and on-going collaboration and communication among caregivers who are focused on provision of seamless care. According to the WHO Study Group on Interprofessional Education and Collaborative Practice, (2008), collaboration is “an active and on-going partnership, often between people from diverse backgrounds, who work together
an “interdisciplinary team approach integrates distinct disciplines that come together into a single consultation……The patient is intimately involved in any discussions regarding their condition or prognosis and the plans about their care.”1
West, S. L., & O'Neal, K. K. (2004). Project D.A.R.E. outcome effectiveness revisited. American Journal of Public Health. doi:10.2105/AJPH.94.6.1027
According to the Case Management Society of America, case management is "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost effective outcomes" (Case Management Society of America [CMSA], 2010). As a method, case management has moved to the forefront of social work practice. The social work profession, along with other fields of study, recognizes the difficulty of locating and accessing comprehensive services to meet needs. Therefore, case managers work with these Case management is a problem-solving practice method that has had a growing momentum over time. This is due in part to federal and state funded program mandates and the desire for continuity of care.
The Canadian health care system is struggling to provide quality care to the growing number of older adults in our acute and long-term care settings. This paper is a self-reflective analysis of caring for the older adult and how communication, clinical skills, and proper hygiene are essential in providing high quality care to older clients. This paper will help determine my weaknesses and strengths, so I can continue to grow as a Practical Nurse and help Canada’s health care system. For the purpose of maintaining confidentiality, I have named my patient Mrs. Holistic in order to adhere to the code of ethics, according to the laws and regulations of the College of Licensed Practical Nurses of Newfoundland and Labrador. Communication One of the fundamental ways to care for an older adult is to have effective communication skills, this allows for you to establish a “therapeutic relationship” (College of Nursing of Ontario, 2006).
As a future nurse practitioner, I have given immense thought to the selection of a clinical practice based on the primary care setting that utilizes the collaboration model. I have selected this type of clinical practice because it best suits my professional and personal goals. I value autonomy while having the ability to work within a healthcare team and enjoy teaching my patients. Nurse practitioners (NPs) are a valuable part of the healthcare team. In the 1960s, from a vision to improve primary healthcare to under-serviced communities, the development of the first NP program developed out of need as a public service and focused on the care of pediatrics and since then the care of other specific populations such as families, adults, geriatrics, and women health has emerged (Anderson & O’Grady, 2009, p. 380).
Intro- Collaboration with the interdisciplinary team plays a big part in the care of a patient.
The chronic care model calls for an organizational change in the way individuals with illnesses are cared for, and the involvement of nurses, social workers and patients themselves. The challenge is moving in an effective way of improving quality from research carried out predominantly in health maintenance organizations to the mainstream of health care practice (Wielawski, 2006). Wagner’s explanation is to substitute the customary physician-centric office structure with one that supports clinical teamwork in association with the patient. The notion spreads outside the health care organization to collaborative associations in the community. Wagner et al. (2001) termed this approach the “chronic care model.” With this model, physicians, nurses, case managers, dieticians, and patient educators
The demands on health care providers to provide the best quality care for patients is increasing. With added responsibilities and demands on our health care workers, it is hard not become overwhelmed and forget the reason and purpose of our profession. However, there is a way where all professionals can meet and come together for a common cause, which is the patient. A new approach in patient care is coming of age. This approach allows all health care professionals to collaborate and explore the roles of other professions in the hope of creating a successful health care team. This approach is referred to as the Interprofessional Collaboration Practice (IPC). To become an effective leader and follower, each professions will need to work together
A patient’s treatment needs may differ widely based on stage of their illness experience. Treatment for a newly diagnosed, moderately ill patient may be very different than the treatment of an end stage, seriously ill patient. In addition, working with patients in various settings as a part of their multi-disciplinary team requires an added consideration of the approach to the staff in the setting. Each patient care setting has a culture of it’s own and requires that a clinician be mindful of how to work with the staff as well as the patient in that particular
This study can help facilitate health care education in varied settings to achieve optimal levels of wellness for the client. Not only does this research help with my knowledge of my community resources, but I can now educate my patient’s on these programs that can become useful for them as they age. This information also helps me utilize the current research to provide client care and pursue lifelong learning to maintain professional growth in my nursing career. After exploring these community resources, I can now demonstrate critical thinking and intellectual curiosity in order to provide holistic care to patients. This information helps support the older adult and family through a variety of health experiences to ensure quality of care.
case coordination for all in the target group with priority to those whose life and wellbeing is at greatest risk.