Potential Barriers Effecting Planning of Mrs Green Discharge Plan - Essay Example

Barriers Affecting Mrs. Green Discharge Plan Name: Course: Instructor: Institution: Date of Submission: Potential Barriers Effecting Planning of Mrs. Green Discharge Plan 1.0. Introduction Mrs. Green is a 78 year old woman who lives alone in a single storey unit. However, she has children and grandchildren who live away from her. Mrs. Green was alone when she experienced the disturbing unrelieved central chest pain and the left shoulder pain for about 10minutes. Later, she was admitted to the emergency department in the hospital where she underwent a cardiac review, leading to her admission due to an angiogram, which may need the stent insertion. Mrs. Green Company is the dog named Matilda. The report will provide some of the main barriers that influence the effective planning for transition care of Mrs. Green. This will include analysing issues such as the adequacy in information provided. The report will include issues such as information adequacy, assumptions from various processes such as cultural, psychological, pathophysiological, spiritual and social process affect the provision of a person. Others include accessibility to community health services including the availability of government subsidies; socio-economic statuses, social capital and ageism as will be shown. 2.1. Information Adequacy Mrs. Green can only leave the hospital when the doctors ascertain she is stable to leave the hospital medically. Besides the medical stability of her health, other issues such as the functional and possible social issues should be considered prior to her discharge. Since, Mrs. Green continued medical care will be given at home, the social and functional issues should be addressed in time prior to her discharge. Mrs. Green’s children are sure that they can provide the anticipated care at home. The discharge processes are influenced by the community services where the health professionals and nurses must give the post-hospital care that will ensure the readmission of Mrs. Green is not presented (Barret, et al., 2009). Thus, to plan for the ongoing care of the patient using information adequacy, the following theories will be applied. The Bronfenbrenner’s ecological systems theory; Bourdieu capital theory, social health determinants and the Bandura’s social learning theory. 2.1.1. The Bronfenbrenner’s Ecological systems theory According to this theory, the environmental systems that each individual (patient) interacts with are considered. That is; the community and society are analyzed through the roles they play in transitioning patients to quality care. The environmental systems are presented in the sections provided. One of the systems is the microsystem, which evaluates the institutions and groups that impact the wellbeing of the patient. Based on this system, one of the main system is the family of Mrs. Green. The family of Mrs. Green is very distant from her. This means that the impact of the family to the health of Mrs. Green is not positive. The transition to care presents that hospital discharge is challenging process for the nurses, the patients and the caregivers. In the case of Mrs. Green, the process is only challenging to the nurses and the patient since she lives alone and has no caregiver. Prior to the transition care, the nurses should ensure that Mrs. Green is physically and mentally capable of managing her health conditions and medications. Thus, though she has proved very independent, it is important that community and family help is provided to her once in a while. When someone else is managing and accessing her health condition, nothing could go wrong. In case Mrs. Green fails to notice an urgent reading or feeling, the provided support will identify it and take the necessary help and procedures to eliminate chances of a readmission to the hospital. Help may be from the neighbours, the family members and other friends. Thus, communication between Mrs. Green and the healthcare professionals in paramount in ensuring the discharge plan and transition of care is effective. Mrs. Green manages her medications. Therefore, she needs to understand how the medications work, the doses she is supposed to take, when to stop taking her medicine among other issues that the health professionals deem important for her conditions and medications. Thus, communication is the main important factor to ensuring that the transition care is effective, and that Mrs. Green has all the information needed or health. Poor communication may lead to adverse events to the patient and nurses may be charged with neglect, which stipulates the need of ensuring the caregivers have the right information. Others may include wrong treatment, and diagnosis delays or mistakes. Thus, given Mrs, Green is the patient and manages her medications, the nurses should ensure she has all the information needed for her condition. Therefore, the hospital and the community, including her family should coordinate through programs that ensures the patients receive all the care they need. Mesosystem is another part of the theory. It presents the interactions of a person, which cannot function independently. Based on this system, Mrs. Green has been performing independently from her family. However, she cannot perform effectively without the care from health professionals. For instance, the hospital should provide a dietician referral to ensure her diet control is managed and experienced effectively. This would assist in improving her health condition through some factors such as been provided with shopping lists, which makes her life much easier. Other parts of the theory include the exosystem, macrosystem and the chronosystem. 2.1.2. Bourdieu’s theory of capital The theory of cultural capital, which presents the social assets of an individual. In our case study, it refers to the social assets of Mrs. Green. Based from the case study, Mrs. Green is not illiterate but she is not completely literate mainly due to her health conditions and age (Currey, 2008). That is; as someone becomes older her literate nature is also affected. But based on the case study provided, she understands her condition quite effectively, which stipulates she is well capable of managing her health. When Mrs. Green is been discharged the nurses should ensure she can follow the guidelines about medication and other information the doctors assume is mandatory. Based on this theory, Mrs. Green has the cultural capital to manage her medications and her health. Economic capital of Mrs. Green can be related to the economic condition of her children, which is assumed to be stable from the case study. However, Mrs. Green does not have any social capital based on her living conditions. That is; when she experienced the pain, she was doing her dishes. Though it is impressive for someone her age to perform such duties for herself, it is important that she has a helper. Mrs. Green lives alone, with her Dog Matilda. Her children are only able to visit over the weekend. Thus, Mrs. Green is socially isolated since she has no interactions with people, which are important in providing and improving the health of many patients. Thus, for effective transition care, Mrs Green should be introduced to some groups of peers where she can communicate and interact with the people living in her community (Ciechanowski, 2011). 2.1.3. Social Determinants of Health This refers to the conditions in which people were born into; the conditions that have shaped their daily lives. In relation to Mrs. Green her health determinants may be linked to the economic stability since it does not show any area she struggled with poverty or such problems. She has children and grandchildren, who even though do not have time to see her constantly, one can tell they love her. Thus, her social conditions are also positive. However, based on her case study and medical information provided in the above; her health problems have been relevant since five years ago when she stopped smoking. Thus, it is possible that her social-health conditions have influenced and led to the poor health she has now where she appears to be suffering from acute coronary syndromes (Australian Commonwealth, 2014). Thus, the health risk of Mrs. Green can be related to the social-health determinant factor. 2.1.4. Bandura’s social learning theory The theory assumes that through learning and observing, one learns some of the perceived behaviors. Thus, learning occurs from the environment where some observe and imitate others to become like them. Thus, based on this theory, it is possible that Mrs. Green can manage her health through observing how the health professional do it, so she can imitate and learn to effectively maintain her health. When communications between the secondary and primary care is not effective, the quality of care given is not certain. When patients are at home, the coordination of communication is challenged, which influences the care given (Graham, et al., 2009). Thus, the nurses should ensure Mrs. Green can learn effectively to guarantee she is capable of managing her health. If she cannot learn effectively, Mrs. Green discharge may be challenging since the communication between her caregiver and the hospital is limited since those with the information (Pham, et al., 2008). The case study presents that Mrs. Green is the one responsible for managing her medication through the T2DM, which also controls the diet. 2.2. Assumptions from various processes 2.2.1. Cultural Culture presents the practices and beliefs that different people have that guide their decisions. Culture occurs as a framework that many people use in analyzing the health care needs. When the nurses understand the cultural value of their patients, the nurse understand the patient way better. These may include how someone responds to pain, fear or anxiety, while defining the role of a sick person (J, et al., 2012). For instance, one needs to understand whether Mrs. Green only takes her medications when in pain. The diet control may also be considered irrelevant on certain occasions or sometimes she just forgets and assumes it is not important. Thus, such information would help in planning a discharge process that includes or the needed information to ensure she attains the needed care or effectively transitions to the care needed. The nurses and other involved parties should understand the potential barriers that hinder effective transition to care or discharge processes (Chang, 2007). 2.2.2. Psychological The psychological function of a patient may influence the information provided to the nurses for effective diagnosis. That is; some patients over-exaggerate or underrate the pain levels or extensions that the pain was perceived. Thus, nurses and other health professionals have to effectively evaluate the condition of patient to be sure of the right discharge planning and how to effectively transition care for the outpatient procedures for Mrs. Green. Mrs. Green should have numerous social interactions to improve her psychological attitudes since people her age due to isolation usually fall into depression, which worsens other health conditions (Ciechanowski, 2011). Thus, her family should find ways to improve her social life through making efforts to visit her often. It may also be through the inclusion of Mrs. Green in programs in the community that increase social interactions, which will be evident in her overall health. Social capital, increases the physical and mental health conditions of any individual let alone patients. 2.2.3. Pathophysiological It refers to the functional changes in a person’s health that follow some diseases or syndromes. Thus, based on the fact that Mrs. Green has been complaining of chest pains and getting solutions through some rest and GNT spray. Thus, the assumptions that her conditions may affect diagnosis and effectively lead to a poor discharge plan that does not influence effective transition care for Mrs. Green (Greenstein & Gould, 2009). 2.2.4. Spiritual and Social process In some cultures, they do not believe in medicine and believe in the power of spiritual forces for healing. In such, they do not refuse to seek medical advice but may refuse to follow doctor’s prescriptions of the hopes of spiritual healing. Thus, to ensure that Mrs. Green consumes her anticipated medication while following the time, it is important that such barriers to effective transition are identified and managed. However, Mrs. Green seems to be a woman who attends church, showing that people in the community help each other. Thus, spiritual process will not interfere with her health, but support her intervention and ensure she gets the help she needs including spiritual support. Socially, some communities believe that old people are not entitled to medications. This stipulates that the community medical services may be hindered to the older people such as Mrs. Green. This may lead to the lack of providing care for Mrs. Green. Therefore, the nurses prior to discharging Mrs. Green should ensure that the community and other social processes do not compete on the attainability of medications and health services (Heath, 2010) (Stranges, et al., 2015). Thus, if the community or individual has such social and spiritual notions, the attainment of effective transition care for Mrs. Green may be hindered. Additionally, on some instances, the health professionals assume that younger people are more deserving of medical services compared to older people. This has led to the older people conditions been ignored as they appear trivial or unnecessary among the caregivers. To avoid such a situation for Mrs. Green it is important that the caregiver’s assumptions regarding those deserving of care are eliminated or irrelevant. All patients regardless of age deserve high quality care. Age discrimination maybe a barrier to transition care as it presents that discharge planning may not be in the best interest for patients (Baillie, et al., 2014). The relationship of Mrs. Green with her family is one of the main social problem that hinders effective transition to health care. The children of Mrs. Green can only visit her during the weekends when they have free time. They stay away from her for full weeks. This stipulates that if she had an emergency where she could not reach the phone to call for help, her health and life would be in jeopardy. Thus, the lack of Mrs. Green’s family understanding the health care she needs including attention stipulates a barrier to effective transition care for her. The lack of constant engagement for Mrs. Green with the nurses, or her family stipulates that she cannot attain the health care needed, based on her medical conditions. Thus, prior to her discharge, the plan should effectively include the help she will get from the community, and how other groups such as the family and nurses will collaborate to ensure she gets the effective transition she needs. Additionally, the lack of clear documentation may hinder effective transition care among her health team and other service providers. 2.3. Accessibility to community health services The community also plays a major role on the discharge process. The nurses have a duty to identify the issues that may hinder the quality continued care of a patient when she is discharged to home care. The community needs to offer services that help in ensuring post hospital care to patients such as Mrs. Green. That is; she is old, stays alone, and has a number of medical problems. The family should be well informed of her condition and what is expected of her or her caregivers to ensure she is not readmitted. That is; the information regarding any referrals done should be communicated effectively, the nurses, family members and the community should ensure she has everything she needs for the home care before readmission to the hospital (New, et al., 2013). Community care services that Mrs. Green should be provided with should be planned before her discharge. The community care professionals should assess the needs of Mrs. Green to determine they can effectively assist in the provision of outpatient care that she may need (Graham, et al., 2009). That is; the community and the family members have to provide Mrs. Green with the support that old people her age including her health conditions require to ensure she supports her health independently even when their services are not available to her. For instance, her family can help hire a caregiver or someone to help with her work at home, which increases her capacity to manage her life and support Mrs. Green’s living style. Based on the case study, Mrs. Green lives in an area where extensive community care to old and retired people is provided. This includes the help given including government subsidies that ensure the needs of people with her conditions have quality care. 3.0. Conclusion The discharge planning is significantly important since it presents the process of providing continued care to outpatients and those who are like Mrs. Green who attain the care at home. It is very important since it eliminates the possible health care gaps that may deteriorate the health of a patient after been discharged. Effective, discharge planning influences the health outcomes of patients like Mrs. Green with T2DM, as it ensures the chances of readmissions are reduced. Discharge plans are effective and should start been prepared the moment a patient gets admitted to the hospital. That is; as the patient stays in the hospital, his or her needs are identified and included in the discharge plan, which ensures effective transition care. It may include considerations such as home follow-ups, communications with the outpatient, community clinicians’ follow-up on the patients’ health and condition including family members since they are all responsible for the patient after been discharged. The plan for effective transition for Mrs. Green involves collaborations from the community in general, family and health professionals. 4.0. References Australian Commonwealth, 2014. Acute Coronary Syndromes Clinical Care Standard. Clinical Care Standards: Australian Commision on Safety and Quality in Health Care, pp. 1-16. Baillie, L. et al., 2014. 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