Students are to choose ONE (1) of the case studies used throughout the semester. Review the literature and analyse the depth of what it means to provide person-centred care and apply it to coordinate

Patient-centered Care

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Part 1

Patient-centered care focuses on the patient’s healthcare needs for a healthier outcome. It is

not all about their health, but instead, it is about them being emotionally, spiritually,

mentally, socially and financially fit. It is evident in many ways such as in the doctor’s office

where patients are given centered care. It also happens in hospitals where the patient decides

who they will see or who they don’t want to visit. Finally, there is personalized medicine as

well as therapies. It goes beyond the regular assessing, diagnosing, and treating of the patient.

As it takes time, having a ‘what else’ approach will make the whole process more patient-

centered than just the patient giving superficial information. Suppose in Agnes’s case, she has

the evident signs of an injury from a fall, but knowing what else is bothering her or in this

case, having her give the practitioner her history is essential (Afilalo, et. al., 2009). From

here, prioritizing the given agendas will not take as much time and will give importance on

what to deal with first.

Part 2

In this case, we have Agnes who is a 67-year old woman who sustained injuries from

a fall at home. The pain made her immobile and injuries included swelling and bruising of

her right leg, a skin tear on her right arm, fractures as well as broken ribs. With the above

information, living well for Agnes will mean having to consider quite some amount of

factors, given her medical and social history (Hubbard, 2010). It is vital for the caregiver to

provide honest information that will make the patients make well-informed decisions.

Older people have complex care and health needs. Themes as frailty can be an issue.

In the case of Agnes, she is 67 years of age, and she lives alone evident by the fact that her

neighbor called the ambulance, the following day. For this case, I would consider frailty as

the central aspect. It is regarded as a state of vulnerability due to poor homeostasis

inflexibility and is usually so after a stressful event causing cumulative degeneration in most

of the physiological systems within a patient’s lifetime. There is a need to come up with more

efficient ways of detecting it, as well as in measuring its seriousness during the clinical

procedural practices. It would be of great help in offering insights as to appropriately select

the elderly for invasive procedures or instead drug treatments. It would also make the basis of

the shift more goal-oriented (Hubbard, 2010).

Person-centered care, in this case, means that Agnes will feel wanted and she will not

face the pressure that comes with the complex disease or nurses being too busy for her.

Instead, patient-centered care means that the counselors and staff members will care for her at

all times. Agnes will have to sit down and explain what is wrong, as she was the only one in

the house when she fell and she knows herself best. For the staff to make a difference, they

need to understand that they are the change and they can make a patient change their thinking

pattern. By smiling or even warmly welcoming Agnes to the hospital and explain the results

from her tests will be a good start (Chaves, Semba & Leng, 2009). As an old woman living

by herself, it is expected that she is lonely and she might want company and warmth in her

injured and immobile state.

Part 3

For successful chronic disease intervention, it is going to need a coordinated

multidisciplinary care team and the central core of the patient’s self-management. A decline

in some functioning will impede the patient’s ability to successfully self-manage the disease

unless treatment and support approaches are provided and adapted accordingly. For a patient

to self-manage will vary depending on areas affected, the severity of the impairments and

complexity of self-care tasks required by the patient. A health provider should however not

be making decisions for the patient concerning treatment and care until they understand their

values and goals e. Patient value, patient priority, and patient goals should be accounted for in

such a call, and the clinician takes the role of ‘convincing’ the patient.

For the best patient-centered care, multidisciplinary attention takes into consideration

each disease or injury into account. Such transformational care will lead to faster answers and

even better results. Instead of blindly diving into the patient's case, a practitioner will be able

to know from which angle to look at the situation. In as much as a patient is referred to

another doctor for assessment and maybe treatment, it is better for the patient to at times go

for such an option in one hospital as it saves on time in critical emergencies and can give the

clinicians a clear understanding of what happened and what they are dealing with. If Agnes

had some part of her treatment done in hospital A, it becomes hard for hospital B to try out

different or even potentially better treatment. Had she been newly diagnosed at hospital B,

then the process becomes easy and faster for hospital B.

How I would care for Agnes is by first realizing that I can be patient-centered in tiny

ways. It could be with the food or the noises, to wanting a family member around. I would

then create an environment that caters to her privacy and to offer better personalized care. By

having a humanistic approach, I will not only help in demystifying the system, but I will also

be playing a part in healing by merely relating to her needs as a human. For Agnes, her needs

are in all aspects - mental, physical, physiological and psychological.

In the case of Agnes, this condition has brought consequences due to the age-related

weakness in most of her physiological system and which will result to her health status

suddenly changing due to the stressor event which was the fall. Complexities will become

evident in all facets of her life as financial, physiological, psychological, social and even

mental.

A multidisciplinary team involved will act in response to changes in the condition of

the disease. Will the situation be managed by medication or will it be through surgery? By

finding and utilizing appropriate resources from people to process to equipment to medicine.

As with old age comes multiple conditions, there is no reason that she cannot live a healthy

and even independent life. Their health and social needs also ought to be taken care of. It os

better when this team works with other health care providers, and maybe even getting insight

from family and friends, to make informed choices about the patient’s treatment, with the

final step being to take action.

It may be hard for her to maintain independence in her home that is why the

multidisciplinary programs needs to identify, assess and treat geriatric conditions as

depression, dementia, falling and incontinence. Such patient-centered care means that

Agnes’s qualities of life will not be affected and the team working together keeps her

independent and safe in her environment offering help when needed.

Prudent self-management requires the clinician to take responsibility in assessing the

patient's current capabilities, identify the barriers to successful self-management and make

efforts to implement management strategies designed and customized for the patient. For

multidisciplinary care, the patient is at the center of everything done. In the case of Agnes,

she will see her medical practitioners from different departments, as oncologists (given her

cancer history), physiotherapists, surgeons or doctor, will not be separated. She will have to

work with her a dietician, those in pathology or laboratory medicine, practice providers,

pharmacists, social workers, and nurses. Pooling experts acts to give the patient an all expert-

surrounded aspect in terms of the care they need. It will enable them to all talk to the patient

together, discuss the issue at hand, and come up with treatment plans together. In as much as

a patient is involved and feels the comfort of knowing what is or will happen, it saves the

patient time and energy of having to make four appointments.

Research has proved that if patients feel like the team of doctors is supportive,

then they become more receptive (Cunningham & Campion, 2015). They get an optimal

treatment plan and a timely start to their treatment, allowing for the better care of the patient.

For this reason, Agnes is likely to positively respond to their concern and treatment knowing

that this ‘team-approach’ she is getting will lead to her peace of mind and appropriate care.

Multidisciplinary care as an approach to Agnes’s case will make me better understand

her needs. Her mobility has been hindered from her swollen and bruised leg, she might have a

hard time breathing, and the skin tear may make doing ordinary things hard. Because of this,

Agnes will need someone who will care for her every need. In the case of seeing her doctors,

she might need to make as little trips to the doctor as possible and having such an approach

and bringing together various specialists makes work easier for Agnes. Together, they will

discuss preventive, and care methods for her and she, on the other hand, can give important,

relevant information regarding her medical history (Streit, 2006).

Self-management skills are to be taught on a regular. Eating healthy and the

importance of exercise are some of the primary ways a patient can look after and control their

health and condition. There are different strategies used when it comes to self-management.

By doing group medical visits to about ten patients, they will all feel heard. This saves time

while still focusing on individual needs despite the group members needing undivided

attention. Another strategy is in actually sitting through with a patient to analyze results or

showing and explaining to them the results. It makes a difference when the topic of the

conversation is the problem affecting the patient, and what the treatment would be. It also

provides security that they are well taken care of (Abadir, 2011). Also, the ‘what else’

approach will help in a patient defining what is bothering them without a clinician having to

interrupt. Though it may seem a bit oversensitive, it shows a patient how much care the

professionals can give. It is also based on research that more positive behavior change over

time came from patients who said they trusted their physicians.

Care coordination is a point of care application used by all members of the

care team including nurses and social workers. The most effective care management program

has been seen to be those where the care team members interact directly with the patients. It

is recommended that web applications be used that will give the list of patients and those who

messaged the doctor, their pending activities as well as a list of appointments (Florini &

Magri, 2002). In as much as it is about providing excellent care, it also about keeping them

well. In providing the education, care and support mean empowering them to be active

partners in their health management, while meeting their goals and needs using their

experience.

Intensive coordination care services work with people who have complex issues. Such

an approach works well with families that have severe issues and could benefit from this

approach. With proactive components like clear communication, coming together of experts

and pooling resources will help in improving patient’s wellness. Explaining to patient’s the

reason and value for their health as well as making them reconsider their priorities, by

mindful awareness they can respond in ways that improve their health. A patient also gets to

find out what works best for them during their recovery or pursuit for better living.

References

Abadir, M.(2011). “The frail renin–angiotensin system”. 27(1), 53–65

Afilalo, J., Karunananthan, S., Eisenberg, J., & Alexander P. (2009). Role of frailty in

patients with cardiovascular disease. 103(14), 1620 - 1630

Chaves, H., Semba R. & Leng, X. (2009) Impact of anemia and cardiovascular disease on

frailty status of community-dwelling older women: the Women’s Health and Aging Studies I

and II.60(8), 720 - 740

Lipsitz, L. (2012 0. Dynamics of stability: the physiologic basis of functional health and

frailty. 57(3), 115–25.

Nuo X., Ding, Q., & Chen, D. (2010).Microglia in the aging brain: relevance to neuro-

degeneration. 5(3), 12-16.

Streit, J. (2006). Microglial senescence: does the brain’s immune system have an expiration

date? 29(6), 506 – 510.

Cunningham C. & Campion, S. (2015). Central and systemic endotoxin challenges

exacerbate the local inflammatory response and increase neuronal death during chronic

neuro-degeneration: Journal of Neuroscience. 25(5), 2275 – 2284.

Florini, J. & Magri, A. (2002). Hormones, growth factors, and myogenic differentiation.

59(7), 1710 - 1715

Lamberts, W. (2007). The endocrinology of aging. 278(3), 419 – 424.

Hubbard, E. (2010). Inflammation and frailty measures in older people. 13(4), 3103 – 3109.