Patient Care Coordination: A Case Study of Liam

Patient care is considered to be one of the most significant and essential functions within healthcare sectors that is provided by healthcare professionals. Often there are times when patients suffer from comorbidities that require the assistance of collaboration and partnership with other relevant organizations as well as professionals, who together can meet the different health and psychological needs of patients which will lead to effective and better health outcomes for them and also make the patient and their family members satisfied with the services (Mantas, 2020).

Hence, the primary aim of the paper is to discuss the case of Liam and the patient care team that is needed to take care of his different needs so that he leads his life normally and participates in his school activities. The paper will also discuss some of the barriers that might be faced by healthcare professionals while implementing the care goals. Apart from this, the paper will also discuss the appropriate care coordination skills that I, as a registered nurse will require to effectively manage the shared care plan of Liam.

Patient Care Team

From the case study of Liam, it is quite evident that he is suffering from both physical as well as mental health conditions. physically he is suffering from JIA (juvenile idiopathic arthritis) or polyarticular since the age of 8 and since the age of 10, he has been suffering from asthma. Both physical health illnesses have aggravated as a result of which he is unable to participate in activities that are being conducted at his school. This has, therefore, had a tremendous impact on the mental health and well-being of Liam.

It should be noted that both physical and mental health illnesses are intertwined with one another and both have an impact on each other. Therefore, as has been reported by Liam’s mother it can be said that Liam is suffering from depression and social isolation as a result of which he has socially withdrawn himself from all types of activities and also does not actively engage in the management of his physical health illnesses of JIA and asthma as he used to in the past. This clearly shows that Liam has lost all confidence and hope and is suffering from poor self-esteem and morale since his physical health condition has worsened with time and he does not see any hope of them being treated as a result of which he is now feeling depressed and lonely.

Patient Care Team

Hence, from the above information, it can clearly be said that an effective, as well as efficient care team, can help in addressing the issues that are being faced by Liam. Thus, for this, the healthcare organization needs to promote the practice of a multidisciplinary team who will be treating various comorbidities of Liam and looking after his different care and treatment needs.

A multidisciplinary team in healthcare consists of nurses, dieticians, staff, doctors, psychologists, social and community care workers who work collaboratively to offer high quality as well as coordinated care to patients that lead to patient and their family satisfaction (Soukup et al., 2018). Liam too is suffering from various types of health issues, therefore, his different health needs are required to be addressed by different healthcare professionals since it leads to better decision-making and quick results (Soukup et al., 2018).

Hence, one of the first members of the care team is healthcare physicians and doctors who will be taking care of the physical health complexity of Liam, prescribe him medicines, and evaluate its progress (Nilsson et al., 2020). The second member of the health care team are nurses who will be administering Liam’s medication, will be offering emotional support to both Liam and his family, and will be responsible for communicating the improving or deteriorating condition of Lian to the concerned doctors and family members (Nilsson et al., 2020). Apart from this, nurses will also educate Liam and his family members on how care can be taken independently at home without being admitted to the hospital. Nurses will also be responsible for teaching strategies to Liam and his parents of how to manage both chronic conditions at home and other places which will help in enhancing the self-esteem of Liam (Pfob et al., 2021).

Apart from this, the healthcare team will also consist of a paediatrician who will not only offer medical care to Liam but will also make him and his family members aware of some of the preventive health services that will help in contributing towards his better health and treatment outcomes (Pfob et al., 2021). The healthcare team will also consist of a physiotherapist who will be teaching Liam and his parents appropriate exercises that will help in controlling Liam’s physical pain and stiffness since he is suffering from JIA. Understanding and practicing of physical exercise will help Liam to keep his pain in control and will thereby also encourage him to take part in different activities.

Barriers to Care

Another essential member who needs to be included in the care team is a psychotherapist or a counsellor who will be responsible for treating Liam off his mental health condition of depression and social isolation by offering him relevant therapies that will boost his confidence, make him overcome his negative feelings and replace them with positive thoughts and ideas (Wood et al., 2018). The counsellor or therapist will also be offering therapy to Liam’s parents since their mental condition too might be affected with continuous deterioration of their son’s health which will thereby help them to effectively participate in their son’s management of mental and physical health conditions (Wood et al., 2018).

A care coordinator will also be included in the multidisciplinary team who will be monitoring the effectiveness of physical and psychological interventions for the next 6 months and ensure that health outcomes are positive and satisfactory for both Liam and his parents (Proctor & Vu 2019).

Social care providers will also be included in the care team who will be making Liam’s family aware of services and programs that will help in lessening their financial burden and will also make them aware of their rights as parents and the type of treatment and services that they can expect from the healthcare organization and the healthcare team in particular (Sinclair, 2019).

Hence, the two chronic illnesses of JIA and asthma are the primary health concerns that need to be addressed by the healthcare since it is due to this reason, that Liam’s mental health condition is being affected. On the other hand, the psychological condition of Liam should be considered to be the secondary element of care that will ultimately help in supporting and encouraging Liam and his parents during the treatment process.

Some of the barriers that Liam and his parents might face during the care treatment and its implementation within the healthcare sector will be discussed in this section. One of the first barriers in meeting the care goals is the ineffectiveness of the multidisciplinary team in understanding the care and treatment needs of Liam (Murphy et al., 2019). In other words, lack of skills and knowledge of the multidisciplinary team will not allow them to effectively understand the mental and physical health issues of Liam and thereby, tremendously affect the process of medication administration and offering support to the concerned individuals (Murphy et al., 2019).

When the care team will lack skills and expertise then it will delay the treatment process and might also lead to inappropriate care and health services being provided to Liam and his parents (Doukanari et al., 2021). Disagreement and lack of coordination and respect between the members of the multidisciplinary team is another significant barrier that will have a tremendous impact on meeting the care goals set for Liam (Doukanari et al., 2021). For instance, different cultural and medical beliefs of the team members will have an impact on the decision-making process and thereby lead to delay in treatment.

Lack of resources and lack of funding is another barrier that will have an impact on the care goal. When there is a lack of funding and resources then health activities and programs cannot be promoted that will affect the treatment process of Liam (Aldawood et al., 2020). On the other hand, if Liam’s parents go through the issue of lack of funding then they will not be able to access the services provided by the multidisciplinary team and will also not be able to get access to healthcare resources that might help in treating Liam (Aldawood et al., 2020).

Therefore, lack of funding and resources will ultimately aggravate the physical and mental health condition of Liam. Lack of staff within the healthcare organization and lack of communication abilities will again act as a barrier in meeting care goals of Liam since different specialists and experts will not be able to meet different needs of Liam and his family that will lead to delay in care and will also not allow the available health practitioners to deliver quality care since they might not have awareness regarding how to treat different health conditions (Rosen et al., 2018).

Lack of adherence and respect for the cultural and religious beliefs of Liam and his family is another significant barrier that might affect the care process. In other words, all the members of the multidisciplinary team should ensure that the treatment they will offer Liam and his family will be clearly aligned to their values and beliefs that will motivate them to respond to treatments which will thereby help in reducing the impact of mental and physical health condition on Liam (Rosen et al., 2018).

Some of the care coordination skills, that I, as a registered nurse will demonstrate to effectively manage the shared care plan of Liam is to practice critical thinking skills that will help me to effectively identify barriers to care which will help me to meet the care goals that have been identified after assessing the health of Liam. If critical thinking skills will not be used then different healthcare needs of the patient will not be identified which is bound to affect the care process (Hewes et al., 2021).

Time management is another care coordination skill that I will need to adhere to since this will help me to make quick and relevant decisions and come up with appropriate interventions that will prevent delay in care which will thereby help in meeting the care goals and at the same time, will also help in overcoming barriers to care (Hewes et al., 2021).

Monitoring for progress and corrective action is another care coordinator skill that will be used while dealing with the health condition of Liam. When there is ineffective monitoring then the progress of patient health will not be effectively identified that will affect in meeting the care goals (Williams et al., 2019). However, when this skill will be demonstrated then it will help in effectively evaluating the care progress which will thereby lead to positive results and health outcomes, thereby helping Liam to manage his physical and mental health illness and overcoming barriers to care (Williams et al., 2019).

There are several technologies that will help in meeting the healthcare needs of Liam. For instance, the healthcare team can make use of telehealth where Liam and his family can take the support and guidance of any member of the multidisciplinary through mobile phone or laptop (Weinstein et al., 2019). Wearables is one of the recent technologies that can be used by healthcare professionals which will help them to monitor the status of the patient throughout the day while they stay at home that will help in evaluating the progress and effectiveness of care plan and at the same time, also offer help and advice when required (Weinstein et al, 2018).

Apart from this, as a registered nurse, I will also try to build relationships and communication by offering community and social care services so that the mental, financial, social, and other needs of the patients can be met and strong treatment response can be guaranteed.

Conclusion

Thus, to conclude it should be noted that the multidisciplinary team will be able to successfully meet the physical and mental health needs of Liam and his family where the registered nurse will successfully make use of care coordination skills that will help in accomplishing the care plan.

References

Aldawood, F., Kazzaz, Y., AlShehri, A., Alali, H., & Al-Surimi, K. (2020). Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool. BMJ open quality, 9(1), e000753. http://dx.doi.org/10.1136/bmjoq-2019-000753

Doukanari, E., Ktoridou, D., Efthymiou, L., & Epaminonda, E. (2021). The quest for sustainable teaching praxis: Opportunities and challenges of multidisciplinary and multicultural teamwork. https://doi.org/10.20944/preprints202010.0148.v2

Hewes, H. A., Genovesi, A. L., Codden, R., Ely, M., Ludwig, L., Macias, C. G., & Olson, L. M. (2021). Ready for Children Part II: Increasing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting. Prehospital Emergency Care, (just-accepted), 1-10. https://doi.org/10.1080/10903127.2021.1942340

Mantas, J. (2020). Transition requirements from problem list to an overarching care plan for the support of person-centered care. The Importance of Health Informatics in Public Health during a Pandemic, 272, 292. https://doi.org/10.3233/SHTI200552

Murphy, M., Curtis, K., & McCloughen, A. (2019). Facilitators and barriers to the clinical application of teamwork skills taught in multidisciplinary simulated trauma team training. Injury, 50(5), 1147-1152. https://doi.org/10.1016/j.injury.2019.01.026

Nilsson, U., Gruen, R., & Myles, P. S. (2020). Postoperative recovery: the importance of the team. Anaesthesia, 75, e158-e164. https://doi.org/10.1111/anae.14869

Pfob, A., Sidey-Gibbons, C., Schuessler, M., Lu, S. C., Xu, C., Dubsky, P., & Heil, J. (2021). Contrast of digital and health literacy between IT and Health care specialists highlights the importance of multidisciplinary teams for digital health—a pilot study. JCO Clinical Cancer Informatics, 5, 734-745. https://doi.org//10.1200/CCI.21.00032

Proctor, R. W., & Vu, K. P. L. (2019). How psychologists help solve real-world problems in multidisciplinary research teams: Introduction to the special issue. American Psychologist, 74(3), 271. http://dx.doi.org/10.1037/amp0000458

Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433. https://doi.org/10.1037/amp0000298

Sinclair, D. (2019). Assembling a collaborative project team: Practical tools including multidisciplinary schedules of services. RIBA Publishing.

Soukup, T., Lamb, B. W., Arora, S., Darzi, A., Sevdalis, N., & Green, J. S. (2018). Successful strategies in implementing a multidisciplinary team working in the care of patients with cancer: an overview and synthesis of the available literature. Journal of multidisciplinary healthcare, 11, 49.  https://doi.org/10.2147/JMDH.S117945

Weinstein, R. S., Krupinski, E. A., & Doarn, C. R. (2018). Clinical examination component of telemedicine, telehealth, mHealth, and connected health medical practices. Medical Clinics, 102(3), 533-544. https://doi.org/10.1016/j.mcna.2018.01.002

Williams, M. D., Asiedu, G. B., Finnie, D., Neely, C., Egginton, J., Rutten, L. J. F., & Jacobson, R. M. (2019). Sustainable care coordination: a qualitative study of primary care provider, administrator, and insurer perspectives. BMC health services research, 19(1), 1-10. https://doi.org/10.1186/s12913-019-3916-5

Wood, L., Williams, C., Billings, J., & Johnson, S. (2019). The role of psychology in a multidisciplinary psychiatric inpatient setting: Perspective from the multidisciplinary team. Psychology and Psychotherapy: Theory, Research and Practice, 92(4), 554-564. https://doi.org/10.1111/papt.12199...