1 / 13

Case scenario, Mrs X for Care Co-ordination

Case scenario, Mrs X for Care Co-ordination. Pip Bourke, Medical Chronic Care Coordinator based at Whitehorse Division of General Practice. Case summary. Female: 56 years old Increased difficulty in self managing No key worker Referral to HARP to address health issues. Case summary. 10.

kioshi
Download Presentation

Case scenario, Mrs X for Care Co-ordination

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case scenario, Mrs X for Care Co-ordination Pip Bourke, Medical Chronic Care Coordinator based at Whitehorse Division of General Practice

  2. Case summary • Female: 56 years old • Increased difficulty in self managing • No key worker • Referral to HARP to address health issues.

  3. Case summary 10 30 16 (19+)

  4. Contributing FactorsU = urgent action; H = high importance; M = medium importance

  5. Contributing FactorsU = urgent action; H = high importance; M = medium importance

  6. Client’s perception of her problems. • Inability to decrease medications for pain without adverse effects • Relationship breakdown with son • Negative body image • Breathing difficulties

  7. The most significant immediate actions.

  8. COMPLEX NEEDS IDENTIFIED • Health issues • Social issues • Cognitive issues • Vulnerable (in living situation) • No effective support from family or friends • Difficult behaviours • Does not recognise need for assistance • Frequently changing and fluctuating needs • Communication/relationship problems • Acute decline in ability to self-manage

  9. Care Coordination Plan • Consistent Communication • All Parties speak the same message • Point of reference • Overlapping of services • Complexity of patient • Clear about whose role

  10. SERVICES INVOLVED IN THIS EPISODE • Local GP • Council HACC services • Rehab in the Home – Physio, Dietitian, Occupational Therapy • HARP Medical Chronic Stream • HARP Aged Care Stream • Complex Care clinic • Outpatients • Pharmacy • State Trustees • Phone Counselling -Community Health Service • RDNS • Oxygen suppliers • Coles meals • MeQWA alarm • Ambulance Service – Transport • Hair Dresser

  11. COMPLEX NEEDS IDENTIFIEDComparison Mrs S and Mrs X • Health issues • Social issues • Cognitive issues • Vulnerable (in living situation) • No effective support from family or friends • Difficult behaviours • Does not recognise need for assistance • Frequently changing and fluctuating needs • Communication/relationship problems • Acute decline in ability to self-manage • Police Problems

  12. Care Coordination PlanQUESTIONS • Who is the Care Coordination Plan for? • Is it the paper of the verbal communication? • Which service provides the Key Worker? • Patient ownership and privacy?????

More Related