Dynamics of Nursing Practice - Mrs Elizabeth Green - Case Study Example

Case World Scenario of Mrs Elizabeth Green Introduction This essay focus on the case study of Mrs Elizabeth Green, who has had a femoral angioplasty performed, she needs the transition of care post hospitalisation. Firstly, this essay will identify the background with transition of care for Mrs Elizabeth Green. Secondly, this essay will analyse the relevant model of care as the foundation for the transition plan. Thirdly, this essay will discuss the availability of information provided, as well as the need for further information to develop a plan of the ongoing care for Mrs Elizabeth Green. Fourthly, this essay will describe the underlying assumptions and potential barriers, in order to plan the transition care effectively for Mrs Elizabeth Green and the general people that require long term health needs. Fifthly, this essay will identify the requirement for and the accessibility to community health services and government subsidies for Mrs Elizabeth Green in the case study and for people in general. Lastly, this essay will make the conclusion, and shows that how all ideas are connected. The background with transition of care for Mrs Elizabeth Green Mrs Elizabeth Green, 78 years old, who lived alone in a single unit, due to the unrelieved chest pain with left shoulder pain, she was sent to the emergency department. Mrs Elizabeth Green had a femoral angioplasty performed because of the left anterior descending occlusion (School of Nursing & Midwifery 2014). After the surgery, Mrs Elizabeth Green preferred to return her own home. Therefore, in order to promote the recovery and keep a healthier life, she needed the transition care that supported by her family members and other health care providers, such as the community nurse, social workers, carers, as well as general practitioners. In addition, there are pretty well established health care services and support networks in Australia, which are leaded and funded by the government and social organizations. Mrs Elizabeth Green can get assessment for her situation, and receives the corresponding assistance to help her keep healthy and to avoid rehospitalisation. Restorative model of care In terms of the transference of health care from the hospital to the home, especially for the elderly with chronic diseases, they need longer periods to recover. Alternative model of care, which also known as restorative care, was provided under the South Australian government and the aged care sector, in order to enable people to restore the normal function or better levels before the admission (Kroemer, Bloor & Fiebig 2004, pp. 266-74). Transition care refers to the post hospital care, especially for the elderly who are in the hospital, it can be provided in the patient’s personal home, as well as in part of an existing nursing home or the medical facility (My Aged Care 2016). Before the elderly receive the community care package, they must be assessed and approved the qualification by the Aged Care Assessment Team (ACAT). A member from the ACTA will make appointment to assess the older people in their home or in the hospital if they are eligible to receive the government subsidised aged care service. The assessment involves the overall needs for the elderly, including medical, physical, social, and psychological aspects. The evaluation team will make recommendations for the preferred setting to receive health care. After the assessment, the Aged Care Assessment Team will let the older people to know their assessment results, and specify the service that they are authorized to accept and the reason for this (My Aged Care 2015).  According to the Aged Care Act 1997, home care is constituted by a wide range of individual care services and medical assistances to older people who do not be provided the residential care. The Home Care Packages Programme provides a coordinated package of services to support the elderly living independently with the aged care and assistances are provided at home. The aged people are eligible to enjoy home care if they have the physical, social or psychological needs, while these needs can be adequately met by the non-residential care service. The Aged Care Assessment Team is required to assess the people if they are in accordance with the eligibility requirements for home care. The structure of a customer's package will depend on the cooperation between the supplier and the consumer, which best to meet their care and support needs. In order to enable the elder people to live healthier in own home with a better quality of life, the home care packages involve a wide range of health services. Home care packages provide tailored personalized services that include personal, family and clinical support and services. Meanwhile, the package may also include aids and equipments, tele-health options and home modification (Aged Care Assessment Programme Guidelines 2015, pp. 39-42). In terms of the case study of Mrs Elizabeth Green, she had performed the femoral angioplasty, with the diagnosis of left anterior descending occlusion and anterior myocardial infarction. Mrs Green preferred to return her own home post hospitalisation. On the one hand, Mrs Elizabeth Green needed to receive professional health care, in order to avoid the complication post angioplasty. Meanwhile, there were several discharge medications that needed to take according to the medical order. In addition, the cardiovascular disease had a greater probability of recurrence, which must be monitored vital signs regularly. Potential barriers and underlying assumptions In order to plan the transition care effectively for Mrs Elizabeth Green and for general people that require long term health needs, the potential barriers, which include pathophysiological, psychological, cultural, spiritual, and social aspects, need to be considered overall. Transition care covers a wide scope of health services that are designed to improve the safe transference of the patient at different health care settings, especially for the high quality transitional care, it is important for the elderly who have multiple chronic diseases, they usually receive health care from different suppliers, and transfer between different health care settings. A number of factors contribute to the gap during the transference for aged people who have multiple chronic diseases that require long term health care at home or in community care settings, which include poor communications, incomplete transition for the patient’s information, lack of education for the elderly and family caregivers, and there is not a single point of people, such as the community nurse, to ensure the continuity for health care all contribute (Naylor & Keating 2008, pp. 58-63). The transition of patients between hospitals and community settings is prone to the medication error, as for the reasons, it may be caused by the inadequate communication between health care providers, missed patient follow-up, lack of the patient education, or the medication reconciliation is not complete, as well as due to the absence of the patient be involved in the medication management (Kristeller 2014, pp. 215-216). Continuous coordination across healthcare is critical, in order to implement and evaluate the patient’s care plan effectively and correctly. The failure of the transference of patient information across different health care settings, such as the error handover information between service suppliers, will result in poor conversion and communication, and lead to the occurrence of errors. This, in turn, can lead to the mistake of the treatment plan, duplicative testing, as well as discrepancies in medications, which missed the nurse to follow up, eventually results the recurrence of diseases that endanger the healthy of patients, and even death. In addition, hospital readmission may cause by the communication failure, the poor coordination of service, incomplete treatment, incomplete discharge plans. In order to make sure the continuity of healthcare, one of the major challenges is to ensure the transference of patient information between different health care suppliers and social or medical institutions, which involves advising the health service provider for the patient’s discharge medication before they admit to new health care settings, ensuring health care suppliers to obtain the complete nursing plan, providing adequate patient educations (Mansukhani, Bridgeman, Candelario & Eckert 2015, pp. 690-694). Consequently, failure in such areas will result in the negative outcomes for the patient recovery and even cause death, especially for the older people with multiple diseases; they are more fragile for such errors. Family caregivers play an important role in supporting the elderly after discharge. However, there is just little attention that has focused on the unique function of family caregivers during the transitional care. As a result, the family caregiver has consistently been poor involved in the decision making of the transitional plan. The job of care giving would be beneficial. However, it will impose a burden for the caregiver at the same time. Stress may increase in the duration of chronic diseases. The nurse or the social worker needs to take care of the emotional needs of caregivers during the transition care, in order to help reduce negative experiences and improve their ability to support the people that they are looking after (Naylor & Keating 2008, pp. 58-63). As for the older people with long term health needs in the community, their children are the mainly family caregiver during the transition care. Meanwhile, caring for the elderly will affect their normal lives as before. The quality of their caring actions will influence the results during the recovery. They also need to be given psychological supports. In addition, the patient with chronic diseases is more easily to suffer from the mental illness, such as depression and anxiety. The mental illness will affect the treatment and recovery of chronic diseases (Perry, Presley-Cantrell & Dhingra 2010, pp. 2337-39). Therefore, the health care provider needs to keep assessing the mental situation of Mrs Elizabeth Green. According to the survey by Albert (et al. 2015, 384-409), they stated that for the patient with cardiovascular diseases, the higher patient socio-economic status, such as the household income or the bachelor degree and higher, will improve the outcomes during the transition care. In terms of the case of Mrs Green and other people with long term health needs, they can enjoy better medical resources which based on the enough income, such as the private insurance or the private doctor. Otherwise, they can only get the most basic medical security. Meanwhile, the higher level of educational degree usually represents a high level of knowledge literacy, they are able to respond to the physical illness correctly, and maintain a positive and optimistic attitude during the recovery period. Community health services and government subsidies There are pretty well established health care services and support networks in Australia, which are leaded and funded by the government and social organizations. The Commonwealth Home Support Programme is made by the Australian Government for the aged care system, in order to help the elderly to live in their home and the community independently. This is a comprehensive program to provide support for the older people who need help to maintain an independent living environment (Ageing and Aged Care 2017). According to the Aged Care Act 1997, the Australian government provides subsidies to approve home care providers, in order to coordinate the package care, services, and case management to meet the needs of the elderly. Individuals will be assessed by the professional assessor that under a nationally unified assessment framework. There are four levels of support, which change from home care Level 1 to Level 4, including the basic care needs, and even high care needs. The Home Care Packages Program is a significant reform to meet the health care needs for older people in Australia. It is important that people have a choice of health care as they grow older, and live longer and healthier. The individual’s priority of care will be identified during the assessment process. Individuals who are approved for the home care packages will be placed in a national queue until a package is available. Home care package recipients are not limited to a basic service list. Approved health care providers will work with each of their customers to select the best service to meet the needs and goals of each person. The Home Care Packages Program provides subsidies for the total amount of available funds for home care packages, while each level of home care package will be provided a different amount of subsidy (Aged Care Assessment Programme Guidelines 2015, pp. 39-42). My Aged Care was introduced on July 1, 2013, it was developed based on a wide range of consulting services in Australia, including individuals, service providers, peak institutions, and government departments. My Aged Care provided information for the elderly, their family members, carers, as well as the service provider (Ageing and Aged Care 2017). In addition, as for the Aged Care Assessment Program (ACAP), the assessment team will take a free assessment for older people before they receive the health service. Meanwhile, the older people’s preferences for choosing their care services and living arrangements will be considered during the assessment process (Aged Care Assessment Programme Guidelines 2015, pp. 22-23). In terms of the situation of Mrs Elizabeth Green in the case study and for people in general, they can apply for the health care service from the above programmes, of which they can get assessment for their situations. And according to the assessment result, they will receive corresponding assistances. Self-care and education Some of the things that the medical team that looks after Elizabeth should undertake are those that she understand her disease that she is and how she should handle. Some of the factors include, determining to what extent is the patient coping with self-management and self-care in managing the situation she is suffering. Whether the patient understands fully matters that deals with diet to ensure that he manages the situation well. Also at this point determination whether the patient understands the relationship that exists between diet and the disease she is suffering from. Whether the patient has received or is ready to receive education that is concerned with education regarding her disease so as to understand how to manage the condition well. Seek to understand whether the patient is a smoker or not. If she is smoker seek to know whether she will be ready to be assisted to get out of the smoking habit. Understand whether the patient has been able to be admitted in the recent past in any hospital with a diabetes related cases. Understand whether the patient has had any treatment in the recent past related to her condition. Understand whether the patient has been having any problem that is different from the disease she is suffering from. Understand the mood of the patient currently and the recent past (Dionne, 2012, pg. 18) When it comes to the control of the disease that Elizabeth is suffering from, culture and religion are some of the barriers that may make it difficult when it comes to handling her condition. There are some cultural practices that usually will par the medical practitioners from fully undertaking the required activities to ensure that the condition of Elizabeth is contained. There are some cultures that are misinformed that make it difficult for patients to take certain deities. They may at end make the patient not to make the meals that should have assisted in controlling the conditions that they are in. Also, some religions may not practice certain practices that will assist in ensuring that the diabetic conditions are contained. There in the case of Mrs. Elizabeth it is important to understand all these to ensure that everything is under control so that no conflict that will occur in the course of treatment. Also, it can be used as a basis of educating her about the disease conditions and how to contain it (Toni, et al, 2001, pg. 13). This will assist her be able to take care of herself once away from the hospital. Contemporary theories According to the contemporary theory which related to the social determinants of health, including Bronfenbrenner’s ecological systems theory, Bourdieu’s theory of capital, and Bandura’s social learning theory, in order to make the transition care plan effectively for Mrs Elizabeth Green post hospitalisation, this essay will analyse the patient information provided and the further information required with contemporary theories. Bronfenbrenner’s ecological theory considers the development of individuals in a broader social context, including microsystem, mesosystem, exosystem, macrosystem, as well as chronosystem, which states a multidimensional affection that it is not only the social system that has an impact on individuals, but also individuals affect these systems (Guerin 2013, p. 58). The social determinants of health refers to the factors that make up the social model of health, it states that each of the social determinants of health describes a set of conditions that affect specific health outcomes. There are four storeys of influence in the social model of health, of which the core layer is individual lifestyle factors. The first outer storey involves the socioeconomic factor, and cultural conditions. The second storey involves education, housing, working environment, unemployment, and healthcare service. The third storey includes the social network and community networks (Parry & Willis 2013, pp. 112-113). In terms of the Bandura’s social learning theory, it refers that the human behaviour is caused by the interaction between the social environment and the personal perception or consciousness (Barkway 2013, p. 160). As for the information provided in the case study, the registered nurse introduced the cardiac rehabilitation nurse to Elizabeth's son and daughter before discharge, meanwhile, Mrs Green was like to attend the cardiac rehabilitation activity, and to make new friends (School of Nursing & Midwifery 2014). In order to develop the transition care plan effectively, there is further information that needs to get. According to the theory of social determinants of health, the social model of health has four storeys of influencing factors, which include socioeconomic conditions, cultural level, environmental conditions, working environment, housing, healthcare services, as well as social and community networks (Parry & Willis 2013, pp. 112-113). Therefore, nurses need to consider the basic information of Mrs Elizabeth Green, such as the housing condition, incomes, education degrees, and social networks. Mrs Elizabeth Green lived alone before she admitted to the hospital. However, after the surgery, she needed someone to look after her. In addition, there were several kinds of discharge medications, which needed to be taken under the supervision of the pharmacist or nurses. Conclusion As to the transference of care from the hospital to the home, especially for older people with chronic diseases, they need longer periods to recover. Meanwhile, the patient with chronic diseases is more easily to suffer from mental illness, such as depression and anxiety (Perry, Presley-Cantrell & Dhingra 2010, pp. 2337-39), which needs the health care provider to keep assessing the mental situation during the transition care. In addition, there are some potential barriers during this period, such as incomplete transfer for the patient’s information, lack of education for the elderly and family caregivers, limited access to basic services, all of these factors will affect the quality of transition care, and lead to the rehospitalisation. According to the theory of social determinants of health, the social factor will affect the outcome for people during the transition care. Therefore, health care providers should analyse the social situation of the patient comprehensively, which includes the socioeconomic status, cultural levels, family members, housing environment, as well as social and community networks. The transitional care planning is a patient centred process, which starts from the assessment for the patient's health care needs to the continuation of the entire patient's stay. The patient and their family members will be provided with appropriate community services, and encouraged to attend the whole decision-making process during the transition care planning (Department of Health 2008). Meanwhile, in order to ensure that the patient's comprehensive needs are met, the health care provider needs to keep communication between patient care teams, reassess for the changed patient medical conditions, as well as the social and cognitive capability. There are well established health care services and support networks in Australia, which are leaded and funded by the government and social organizations, the elderly can receive the corresponding health care assistance according to their personal wishes, as well as assessment results by the Aged Care Assessment Team. 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