Interdisciplinary Team Case Study

The majority population of long-term health facilities is comprised of geriatric patients with complex comorbidities. Studies show that one-third of these patients have cognitive impairments, and over one-half have physical limitations (Tjia, Bonner, Briesacher, McGee, Terrill & Miller, 2009). It is important to know geriatric patients have increased vulnerabilities. When patients are poor historians and family is unavailable, the nurse often becomes their only advocate during facility admissions. Adequate discharge planning is imperative for patient safety and successful transitions from hospitals to long-term care facilities. It is the equal responsibility of both care

Creating new support for modernizing multipurpose senior centers including a plan to use the skills and services of older individuals in pain and unpaid

Long-term care can be defined as a broad set of paid and unpaid services for people who are mentally or physically disabled, or whose chronic illness places them in need of medical or personal assistance for long periods of time. “It is estimated that there are more than twelve million Americans of all ages whose mix of serious disability and chronic illness places them at the high risk for functional decline, hospitalization, or nursing home placement.” (Benjamin) Several different populations require long-term care services, and the needs of these populations vary. In addition to the elderly, many of the long-term care users are younger persons with physical disabilities; persons with developmental disabilities; and persons with chronic

I have scheduled an interview and time to observe a nurse leader with the Director of Nursing (DON) for the Virginian Nursing and Rehab facility in Fairfax, Virginia for Thursday October 2, 2014 at 7:30am. I plan on spending a full eight-hour shift with the nurse leader observing the following three leadership activities: 1) Observing her making rounds on the units 2) Observing and or participating in a nursing leadership meeting and 3) Observing the facility’s interdisciplinary team meeting.

Types and number of staff that this facility needs, and the rationale for this. How these needs differ in facilities that attend to different long-term care populations

The Continuum of Care is the variety of health care services provided to numerous individuals who are in need of it. All the various Long Term Care providers work as a unit, helping an individual handle their disability with various health care amenities accessible. The Continuum of Care, as stated in Long Term Care: Managing Across the Continuum (2010), is “comprehensive, integrated, and client-oriented”. All the services offered should be client-based and cater to the client’s needs and suitable care. The client’s should be able to obtain services when it is needed from the provider, making it comprehensive. All the different Long Term Care providers should be interconnected between one another, because their goal is all the same. Their goal is to care for the client’s needs. The Continuum of Care consists of: nursing facilities, sub acute care, assisted living, residential care, elderly housing, and a variety of community-based services (Pratt, 2010). All these different providers work together to care for the individuals within the health care industry, creating the continuum and making it integrated. The continuum has many positive attributes, along with many barriers. The range of barriers are: poor transitions from Long Term Care setting to setting for the clients, the continuum is reimbursement-driven, it is fragmented and uncoordinated, it is under staffed with medical professionals, and there are major language and literacy problems.

The long-term care services delivery system in the United States has changed substantially over the last 30 years . There are approximately 17,000 elderly and disabled persons are receiving care in nursing homes (NNHS, 2004). The number of people using nursing facilities, alternative residential care places, or home care services are projected to increase from 15 million in 2000 to 27 million in 2050 (HHS, 2003). Identifying the best nursing home that would fit their needs can be difficult and time-consuming. Although nursing homes usually provide certain basic care that patients need, some nursing home facilities provides special care for certain types of individuals with special needs. For example, people with dementia, AIDS, ventilator-dependents,

Mr. Henry and his wife need medical care coordinated throughout the health care system to receive proper treatment and prevent health complications, encouraging their independence by remaining in the same setting. Marek and Rantz highlight that by providing care coordination and health care services for older adults residing in specially designed senior apartments, older adults will not have to move from one level of care delivery to another as their health care needs increase; and they will have the opportunity to “age in place” (Marek & Rantz, 2000). Care coordination starts with a comprehensive assessment of each of Henry and Ertha individual needs for health and social support, and by developing an individualized plan of care for each of them. “Patients should be evaluated, and care plans should be designed and implemented according to the individual needs of each patient (American Geriatrics Society, 2012, p. 1966). As Mr. Henry and his wife health care needs increase, they can receive periodical physical examinations to monitor their underlying health problems, and for early detection of complications remaining in their apartment. This will prevent negative outcomes associated with relocation, and medications and treatment noncompliance.

In many circumstances, people may move out of long-term care. Those recovering illness or injury may regain independence after they are well. Some may not every be able to live a life without long-term care again. It is noted that 40 percent of people over 65 will need two or more years of long-term care with half of those needing care for more than five years (Grote, 2011). Unfortunately, with today’s aging population, the numbers in the long-term care are most likely to keep increasing instead of transitioning people out. Of the 12 million people who need LTC, 6.6 million are age 65 or older and are likely to be Medicare beneficiaries and entitled to the LTC coverage that Medicare provides (Barton, 2006). That said, not everyone who

Throughout Unit 6 we reviewed the continuum of care in long-term care facilities and its many aspects. The continuum of care, also referred to as the delivery system of health care, is best defined as a full range of long-term care services increasing in level of acuity and complexity from one end to the other (PowerPoint). This delivery system is comprised of three substantial components. These components are the informal system, community based care, and the institutional system.

The necessity for long-term care is increasing which will require additional training and education for health care personnel, family members, and patients. Family members can have peace of mind knowing their family member will gain confidence in learning how to become accustomed to his or her new life while maintaining a quality continuum of care during and after treatment for physical, mental, or age associated illnesses.

Health care is a fascinating industry. So many types of care are included within the industry. Health care can be very broad or very specific. Health care is also comprised of different types of health care. One specific sector is long-term health care. Long-term care plays a huge role in the health care continuum. This paper will define long-term care and a continuum as well as discuss the services provided and how these services fit in the continuum of care, the resources that go along with long-term care and how it contributes to overall health care resources, and how long-term care services

To ensure the best health care provided to older adults, nurses need to apply the nursing process to all their patients to reduce their hospitalization and help them live better lives. This also provides the health care provider all the information needed to plan their care. L. Lilley, S. Collins, and J. Snyder (2013) explain the importance of lifespan considerations with elderly patients, “More than 80% of patients taking eight or more drugs have one or more chronic illnesses. More complicated medication regimes predispose elderly patients to self-medication errors, especially those with reduced visual acuity and manual dexterity.” (p. 43) Considering our patients age of being over 65, special considerations are needed

Therefore, he promotes his idea about integrated delivery system to the board, and he forms a group called “The Geriatric assessment and Care Planning Team” which gather medical, rehabilitation, social services, nursing staffs to work together on resident health assessment. But his plan bristled with difficulties.

at the time of your visit. We have divided the DGA in two parts, each with three