CAU Communication of Patient Information During Transitions in Care Case Discussion

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Carlos Albizu University

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Intro to Healthcare Management

Part 1

Discussion Prompt 1-3 Paragraphs

Read the case study from pp. 570–571 of your text: Communication of Patient Information During Transitions in Care

  • What are the facts of this case?
  • Review the quality improvement tools in Chapter 7 and select the appropriate one to analyze this problem.
  • What are the top three management issues in this case?
  • What are the legal and ethical obligations a healthcare organization has to its patients and families, and how do they apply to this case?

Part 2

Assignment: Interpersonal and Interprofessional Relationships

Objective: To understand interprofessional and interpersonal relations in healthcare facilities

Instructions:
You are the new administrator in a long-term care facility with a rehabilitation wing. There are three residents/patients that need care in your facility.

Patient 1
Mrs. Smith, 65, recently lost her husband. She has diabetes and is unable to walk without a cane. Mrs. Smith has not been leaving her room much except to purchase snacks at the commissary.

Patient 2
Mr. Jones, 48, recently left the hospital with a compound fracture to his hip. He is angry that he was not allowed to go straight home and is upset that he needs help with activities of daily living (ADL).

Patient 3
Mrs. Eccles, 72, has been in the nursing home for many years but has recently started to be forgetful and seems unable to manage tasks that she had been doing by herself.



Review the Meet the Long-Term Care Facility Practitioners interactive infographic.(Attached word document)

Using your textbook, the infographic, and the resources provided in the reference list below as a guide, determine which people will be involved in the care for each of the three residents/patients. After you have made your decisions, compose a small care plan for each person. This will involve determining the roles each of the practitioners have in providing care, and assessing who will be involved with each patient. For example, you may determine that Mrs. Smith is in bereavement—who would be involved in getting Mrs. Smith through this?

References
All Nursing Schools. (2018). Read a Certified Nursing Assistant job description: What you’ll do as a CNA. Retrieved from https://www.allnursingschools.com/certified-nursing-assistant/job-description/

Cantor, M. D. (2017). We need more geriatricians, not more primary care physicians. Retrieved from https://catalyst.nejm.org/need-more-geriatricians-primary-care/

Colorado Physical. (2017). The physical therapy role in a skilled nursing facility. Retrieved from https://coloradophysicaltherapynetwork.com/physical-therapy-role-skilled-nursing-facililty/

Greenwood, B. (2018). Duties of a nursing home social worker. Retrieved from https://work.chron.com/duties-nursing-home-social-worker-22711.html

Miller, A. (2018). What are the duties of the activities director? Retrieved from https://work.chron.com/duties-activities-director-26711.html

Ray, L. (2018). How to become a certified med tech. Retrieved from https://woman.thenest.com/become-certified-med-tech-10425.html

RD Nutrition Consultant Staff. (2018). The role of registered dieticians in long-term care. Retrieved from https://www.rdnutritionconsultants.com/single-post/2018/05/19/The-Role-of-Registered-Dietitians-in-Long-Term-Care

Visiting Nurse and Hospice Care. (2017). Bereavement support and counseling. Retrieved from https://www.vnhcsb.org/bereavement/

Unformatted Attachment Preview

Interaction Take a few minutes to click on each person. You will meet the practitioners of a long-term care facility with a rehabilitation wing to help you understand their roles with patients. Sandy, Social Worker Hi, there! My name is Sandy and I am a social worker. I am employed by the facility to work five days a week. I help to assess every resident when they first arrive. Most of the residents I help weekly are having difficulty getting over something. The loss of a loved one is the number one thing I help residents to accept, but I also help with anger and frustration from the loss of independence. Reginald, Medical Technician Hello, I am Reginald, the medication technician. My job is to help the nurses give the residents their daily medications. Some of my residents have to be given medication up to six times a day, so I really get to know them. July, Certified Nurse Aide (CNA) Hi, my name is July and I am a CNA. I typically work with many residents starting on their first day in the building, although there are some residents who do not need my help. I help those under my care every day first thing in the morning. I help them get out of bed and to the bathroom. There are some residents that cannot use the bathroom, so I help them with continence control and brief changing (please, never call them diapers!). I also feed and dress most of my residents, and do light cleaning in their rooms. Stephen, Physical Therapist Good morning, my name is Stephen and I am a physical therapist. Although I help a lot of residents who have arthritis and need extension movements, my main purpose at the nursing home is to help the younger clients who were sent here from the hospital for rehabilitation following a surgery, an accident, or some other injury. I am here five days a week for eight hours each day. I typically work with residents for 14-minute sessions. Some residents may require more than one session a day, but most are daily for one session. Dr. Shaw, Geriatrician Hello, my name is Dr. Shaw, and I am a geriatrician. I am a consultant at the nursing home, and I make rounds there three times each week. Think of me as a doctor who makes house calls—at the facility. I specialize in dementia, Alzheimer’s, and other forms of cognitive issues. David, Bereavement Counselor My name is David and I work alongside Sandy to help our residents who are having an extra tough time with the loss of their loved ones. I only come to the facility twice a week, but because bereavement is not a simple transition, it is covered by insurance for 13 months. I conduct individual counseling and facilitate the support groups for both the men and women. Cynthia, Activities Director Hi, I’m Cynthia and I am the activities director. Quite honestly, my main job is to get every resident out of the room and interacting somehow; it can be as simple as watching others do something. But I gain their trust and find out what interests them, and then I work on daily and weekly activities to get the residents moving and involved. We go on trips weekly, but I am also tasked with morning, afternoon, and evening activities to accommodate everyone’s interest. Peter, Registered Dietician Good morning, my name is Peter. As a registered dietician, I do much more than helping to plan meals. I counsel residents when they first come to the facility, and then I follow up weekly to oversee nutritional needs. I am especially involved in nursing homes because residents have medication, allergies, diseases such as diabetes, and other issues that require a therapeutic diet. I have to be involved in meal planning for residents who easily aspirate (those who choke, like my residents with Alzheimer’s). Introduction to Health Care Management, Third Edition Sharon B. Buchbinder and Nancy H. Shanks Communication of Patient Information During Transitions in Care By Sharon Saracino and Sharon Buchbinder Margaret Burns is a 63-year-old woman who has suffered a left occipital hemorrhagic infarct, a cerebrovascular event. In addition to this recent stroke, Margaret has a history of rheumatoid arthritis, which limits her mobility; hypertension, which has been controlled with diet and medication; osteoporosis; gastroesophageal reflux; and depression. She is alert and oriented, and has been identified at risk for falls. She requires moderate assistance with transfers and minimal assistance with ambulation using a rolling walker. Her scheduled medications include: pantoprazole for gastroesophageal reflux disorder (GERD); alendronic acid for osteoporosis; prednisone, a steroid; metoprolol for hypertension and heart disease; and calcium with vitamin D. Following her acute care hospitalization, she is transferred to a skilled nursing and rehabilitation facility to continue her recovery. Margaret lives alone and must be independent to return home. One week after her admission to the skilled nursing facility, Margaret develops pain and swelling in her right leg and a low grade temperature. Her blood work indicates an elevated white blood cell count. The attending physician orders a venous Doppler ultrasound of the right leg and the results are positive for an acute deep vein thrombosis (DVT). Plans are made to transfer Margaret back to the acute care hospital for possible placement of a filter as she is not a candidate for anticoagulation due to her hemorrhagic stroke. Carol Stevens, the secretary on Margaret’s unit, had a flat tire on the way to work. After calling the auto club and waiting for them to come and change the tire, she arrives late, already behind before her day has even started. After she punches in and hurries to the unit, she learns two patients are being discharged, two patients are scheduled to arrive for admission, and Mrs. Burns is scheduled to be transferred to the acute care setting. She immediately sets to work faxing the histories, current lab results, consults, diagnostics, physician progress notes, nurses’ notes, and medication administration records to the physicians of the patients to be discharged and making copies of those items to send to the hospital with Mrs. Burns per protocol for continuity of care, keeping each set of patient records in a separate pile. Carol’s son then calls to say that he missed the school bus. Carol sets the papers aside while she calls a neighbor to arrange transportation for her son. As she hangs up the phone, the ambulance arrives to transport Margaret to the hospital. Carol gathers the copies of Margaret’s records together and places them in an envelope. The hospital process is for a nurse to double check the records to ensure they are correct prior to the patient leaving the building, but another ambulance crew arrives simultaneously with a patient for admission, handing that patient’s paperwork to Carol. Carol hands the envelope with Margaret’s records to the first crew and directs them to Margaret’s room. A week later, the patient care coordinator at the skilled nursing and rehabilitation facility receives a call from the acute care hospital and is informed the medication administration © 2017 Jones & Bartlett Learning, LLC 1 Introduction to Health Care Management, Third Edition Sharon B. Buchbinder and Nancy H. Shanks record sent with Margaret Burns was that of another patient. The acute care hospital failed to notice this discrepancy on admission, and the wrong medications were ordered and administered to Margaret for three days. Margaret suffered an extension of her hemorrhagic stroke and was transferred to the ICU. © 2017 Jones & Bartlett Learning, LLC 2
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Running Head: HEALTHCARE MANAGEMENT

Healthcare Management
Student Name
Institution Affiliation
Course
Date

1

HEALTHCARE MANAGEMENT

2

Intro to Healthcare Management
Part 1
1. Facts about the case
Margaret Burns is a 63-year-old woman who has been discharged and relocated to a
professional treatment center in order to better her life prior to her recovery. She experiences
discomfort, swelling in the right eye, and fever when in the certified hospital. An ultrasound is
performed to identify a DVT. Margaret is ready to be admitted to an emergency care facility, but
she crosses the documents with other patients and takes the wrong medications.
2. The appropriate improvement tool for this problem
In this situation, I believe that it will be essential to use the FOCUS-PDCA System to
enhance Mrs. Burns' treatment. FOCUS is short to find, organize, clarify, understand, and select.
PDCA would be an appropriate approach for me to plan, determine what to do, check
requirements, and act accordingly. The facility will create a strategy to prevent that happening by
identifying the problem and fixing the problem.
3. Top management issues in this case
The protocol was not observed to double-check the directives and ensure that Mrs. Burns
had the right directions before she entered the house. Before offering the medicine to Mrs. Burns,
the Hospita...


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