Complex Care

The Youbeaut Clinic has been accepted to participate in the NSW Healthcare Homes program. As the senior RN in the practice you have been the given the task of care coordinator for patients who have agreed to participate it the program.

Liam is a 15-year-old male patient who has recently joined the program. You have not met Liam previously and he and his mother, Erica, are due to attend the surgery later today. In preparation for Liam’s appointment you review his patient’s notes and shared care plan. On review you note that the shared care plan has been started however is not yet complete.

 

Task

Review the attached case study of Liam and his shared care plan then answer the following questions:

Part one

Complete the missing information on Liam’s care plan and provide the relevant information;

  1. Patient Care Team: Identify all of the facilities, organisations and professionals Liam and his parents will have to access/interact with to achieve his treatment goals. Separate these into primary secondary or other (if relevant) and document the referral process and their role in Liams’ care.
  2. Patient’s barriers to care goals:  Review the patient care goals identified on the care plan. Identify barriers for achieving the care goals (note: may be: medical, situational system. Consider self-management strategies, health literacy and the team goals, this is not exhaustive).

Part two

Role of the RN as the complex care coordinator to deliver the shared Care Plan

  1. Nursing practice: Outline the relevant care coordination skills you as the Registered Nurses require to effectively manage Liam’s shared care plan.
  2. Identify Strategies: As the complex care coordinator you have to effectively implement Liam’s shared care plan. Identify any/all projects, programs, technology, organisations, innovations etc. that would assist with delivering the goals identified in Liam’s shared care plan.
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