HSE210 Milestone Three Guidelines and Ru
ic Follow-Up Care Plan and Conclusion (Sections IV and V)
HSE210 Milestone Three Guidelines and Ru
ic
Follow-Up Care Plan and Conclusion (Sections IV and V)
Overview: In your final milestone in preparation for your final project submission, you will work on a draft of the follow-up care plan and conclusion to your
collaborative care guide. As with previous milestones, you will be working on these elements as they relate to Jean’s 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, transfe
ing 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 cu
ent lack of mobility is weighing heavily on her psychologically. Despite her cu
ent
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 cu
ently 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.
The follow-up care plan occurs after discharge from the hospital. The initial discharge plan addresses immediate needs of the client as he or she transitions back
to his or her home. Once that transition is complete, some issues remain. These are the issues that will be addressed in the follow-up care plan. Consider
agencies in the community that can assist the patient in addressing the issues. As you work on your plan, you may find the following resources valuable:
ï‚· Improving Hospital Discharge Planning for Elderly Patients
ï‚· Best Practices Manual for Discharge Planning
Prompt: Create a draft of Sections IV and V of your final project, a collaborative care guide.
IV. Follow-Up Care P lan
Create a comprehensive follow-up care plan for Jean, applying her needs identified in the case study.
A. Applying best practices, explain the basic post-discharge client needs represented within the case study.
B. Develop strategies to a
ange provision of services to the client.
http:
www.ncbi.nlm.nih.gov/pmc/articles/PMC4194477
https:
www.myflfamilies.com/publicnotices/20150519resource2.pdf
C. Develop effective strategies to address the client’s post-discharge financial needs. What strategies will you use to ensure client access to
ecommended services?
Consider organizing this section of your milestone in table format:
Client Needs (Including Financial Needs) from the Case Study
Issue 1:
Issue 2:
Issue3:
Issue 4:
Issue 5:
Strategies to Address Needs and Suggested Agencies
That Will Provide Needed Services (Including Financial Needs)
Issue Strategy and Agency/Source of Services
V. Conclusion
Discuss the impact of navigating available resources for both inpatient and discharge needs on the client in the short and long terms. Finally, describe
the expected outcomes of the care plan. Be sure to include the following:
A. Based on the case study, how would the difficulty of navigating the available resources for both inpatient and discharge needs impact the client
physically and psychologically?
B. What long-term effects will the strategies you developed for addressing the client’s inpatient and post-discharge financial deficits potentially
have on her survival and well-being?
C. Describe the expected outcomes of this care plan. Given the follow-up care plan and the anticipated impact of available resources, what realistic
outcomes for the patient do you foresee? Consider physical, emotional, and financial outcomes.
Guidelines for Submission: Your draft of Sections IV and V should be about 2 to 3 pages in length and should use double spacing, 12-point Times New Roman
font, one-inch