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Collaboration with Multi-disciplinary Team

Dicuss about the Integrative case Management.

The members of the multidisciplinary team are physician, nurses, physiotherapists, pharmacist, personal support worker, family members, relatives, and society people.

I will collaborate with the concerning physician, to get update on the current health status and lab diagnosis.  He will be consulted for prescribed medication and action plan to reduce the progress of disease. I will collaborate with nurse to ensure that the HGB levels are regularly monitored and the patient’s risk of fall is assessed. Further collaboration with the physiotherapist is necessary to assist patient with mobilization needs and strengthening of the body movements through exercises to help with activities of daily living (Brown et al., 2016). To help the family and the patient financially, collaboration with social worker is necessary. The family members and relatives may be involved to give enhanced emotional support to the client. They will be provided with the knowledge of medication side effects and need of assisting the patient with on time medication to prevent nausea and vomiting. Family members will be encouraged to provide supportive and calm environment (Meguid et al., 2016). 

I will update the all team members, about the patient by collecting feedback from the patient and their family. Using the information, I will discuss directly with the nurses and the physician to modify the care goals if needed and changes in medication. Further using the social media app based system I can keep all the members regularly updated about the patient needs and disease status, side effects of medication and input/output (Rolls et al., 2016).

Further nutritionist may be consulted for the client to have the proper diet. It may include Iron rich diet to help reduce GI bleeding. Te fluid may be educated to have well balanced diet and maintain the fluid recommendations. It will help get relieve from the urinary incontinency (Heffernan-Swingle et al., 2016).

Integrative case management is the process by which different range of health services is effectively combined and integrated to provide the best and seamless service delivery to patient. It is also client-centered process or system that fulfills all the unique needs of client with the support of multi-professional team members (Vourlekis, 2017).  Based on the review of the case study of P.W, a 77 year old patient diagnosed with G.I bleed and indeterminate pulmonary nodules, it has been found that she needs family support and empathy to effectively cope up with her family members. Secondly, she is also in need of support from a physiotherapist and a social workers who can assist her in daily life activities and meeting her financial needs to maintain her health. As Mrs. P.W has been constantly experiencing health issues like swelling in the hands, nausea and weakness, the support of a clinician is also important for her to control her symptoms. Hence, all the above multi-professional groups need to collaborate, coordinate and come together with shared goals to practice integrative case management service delivery.

The social worker, physician, family members and physiotherapist can engage in integrated case management service delivery by following the principles of coordination, collaboration and integration. As all the above members are working to address certain specific need of Mrs. P.W., they need to come together and share information through appropriate networks. This will make all members aware about the services or health care support that is provided to client and this may also enable them to arrange a program that addresses common client needs (Goodwin et al., 2015).  This is an example of proper collaboration process to promote integrative service delivery. Secondly, to engage in proper coordination process while fulfilling health needs or psychosocial needs of Mrs. P.W, the members with the similar goal or activities can come together to plan activities around the needs of the client. This form of partnership can effectively fulfill unmet needs of patient if the services are accurately streamlines to provide seamless service delivery to patient. Lastly, integration of service can be possible when all the team members agree to the ultimate goal of promoting health and well-being of client. During interaction with client, if the family member of physiotherapist discovers the need for other resources to provide care to patient, then the possibility for new resources or systems should be considered too. The above mentions factors promote integrated working between health care and social care services (Cameron et al., 2014).

Roles of the Different Team Members for the Patient

Another approach that is needed to practice integrative case management service delivery is to create an open information sharing network so that each types of professionals and the agencies involved can establish ongoing ties to maintain the continuum of integration. The effectiveness of integrated case management can also be enhanced by considering the possibility of duplication of activities and resources and taking systematic approach to minimize waste of resource (Waibel et al., 2015). Hence, agreed plans and protocol will help to maintain strong professional relationship between different team members and fulfillment of all patient-centered goals. As the support of physiotherapist and physician is needed to assist Mrs. P.W in daily activity and symptom improvement, it is also planned to improve the quality of integrated service by considering additional resources that would improve the quality of their service, This involves using common assessment tool for transferability of information. Secondly, in case, resource is needed for assistance in daily activities and exercise, then the social worker need to be contacted too to get the resources at low cost. Such integrative practice has the potential to reduce the burden of the client and be prepared to address complex needs of the patient.

Interview skills are necessary for patient advocacy. Case study person may require support with mental health. She may be refereed to motivational counseling to deal with stress caused by disease and financial implications.  The need in this area may be identified through effective interpersonal communication and interview to assess and facilitate the patient with better understanding with the health care team and provide with educational resources while teaching.  At the time of interview the patient’s right and dignity will be maintained and involves her opinion in decision-making.  Teaching may be focused on medication complications that the patient should be aware of.  To maintain good quality of health after discharge the patient may be advocated with additional support system that can be accessed though community resources or programs. During communication appropriate verbal, nonverbal and body movements will be maintained.  To make the client feel safe, her values and preferences will be taken and cultural factors will be considered during hospital stay I will advocate for third party payer  (Saypol et al., 2015).

While implementing the integrative case management plan for Mrs. P.W, it is also necessary to fulfill all relevant ethical consideration that can be applied for her. As the patient is a 77 year old patient, all ethical consideration related to the ageing process and fulfilling the needs of aged person is necessary. Some of the important ethical consideration that needs to be fulfilled to provide integrative case management service delivery to patients are informed consent requirement, confidentiality factor and patient autonomy factor (Tribe & Morrissey, 2015). The process of informed consent needs to be followed before delivering the service to Mrs. P.W. She needs to be made aware about types of services that will be provided to her and the reason for providing such service. After giving this information and possible outcomes of the program, the service delivery can be started only after she gives consent for such service. This will also help to fulfill the principle of patient autonomy during care. Secondly, to address the ethical consideration related to confidentiality, all involved members must be made aware about the privacy and confidentiality requirement and the need to preserve and protect client information. All involved members and agencies must also be explained regarding the limits imposed for disclosure of client information to others (Fagerberg & Engström, 2012).

References

Brown, A., Wylie, N., Rodgers, M., Casement, J., McIlree, N., Gray, L., ... & Koea, J. B. (2016). Development and initial outcomes of an upper gastrointestinal multi-disciplinary clinic. The New Zealand medical journal, 129(1437), 48-54.

Cameron, A., Lart, R., Bostock, L. and Coomber, C., 2014. Factors that promote and hinder joint and integrated working between health and social care services: a review of research literature. Health & social care in the community, 22(3), pp.225-233.

Fagerberg, I., & Engström, G. (2012). Care of the old—A matter of ethics, organization and relationships. International journal of qualitative studies on health and well-being, 7(1), 9684.

Heffernan-Swingle, E., Radler, D. R., Marcus, A., Ireton-Jones, C., & Touger-Decker, R. (2016). Change in Self Reported Gastrointestinal Symptom Severity and Frequency following a Registered Dietitian Counseling Session for the Management of Irritable Bowel Syndrome. Journal of the Academy of Nutrition and Dietetics, 116(9), A74.

Meguid, C., Schulick, R. D., Schefter, T. E., Lieu, C. H., Boniface, M., Williams, N., ... & Edil, B. H. (2016). The multidisciplinary approach to GI cancer results in change of diagnosis and management of patients. Multidisciplinary care impacts diagnosis and management of patients. Annals of surgical oncology, 23(12), 3986-3990.

Rolls, K., Hansen, M., Jackson, D., & Elliott, D. (2016). How health care professionals use social media to create virtual communities: an integrative review. Journal of medical Internet research, 18(6).

Saypol, B., Drossman, D. A., Schmulson, M. J., Olano, C., Halpert, A., Aderoju, A., & Chang, L. (2015). A review of three educational projects using interactive theater to improve physician-patient communication when treating patients with irritable bowel syndrome. Revista Española de Enfermedades Digestivas, 107(5), 268-273.

Tribe, R., & Morrissey, J. (Eds.). (2015). Handbook of professional and ethical practice for psychologists, counsellors and psychotherapists. Routledge.

Vourlekis, B. (Ed.). (2017). Social work case management. Routledge.

Waibel, S., Vargas, I., Aller, M. B., Gusmão, R., Henao, D., & Vázquez, M. L. (2015). The performance of integrated health care networks in continuity of care: a qualitative multiple case study of COPD patients. International journal of integrated care, 15(3).

Wodchis, W., Dixon, A., Anderson, G. and Goodwin, N., 2015. Integrating care for older people with complex needs: key insights and lessons from a seven-country cross-case analysis. International Journal of Integrated Care, 15(6).

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