Engaging Diverse Professionals in the Plan of Care

Case Study: Engaging Diverse Professionals in the Plan of Care

Joseph Kane is a 78-year-old widowed male who lives alone. Two weeks ago, his adult son and daughter-in-law became alarmed when he didn’t come to their home for Sunday brunch as was his routine. His son, Jeff, called Mr. Kane on the phone and got no answer, so he went to Mr. Kane’s home. Jeff found Mr. Kane lying on the floor in the kitchen. Mr. Kane did not seem to understand what was happening and was soaked in urine. Because there were no lights on in the home and because Mr. Kane’s car keys, unopened mail, and a bag of groceries were on the table, it was estimated that he had been lying there for more than 20 hours. Mr. Kane was transported to the trauma center via ambulance, where he was diagnosed as having an acute left-sided cerebrovascular accident (CVA), or stroke. Mr. Kane was admitted to the stroke unit. As a result of his CVA, he is unable to move the right side of his body and has difficulty understanding and expressing verbal communication. He appears confused and frightened at times but is able to cooperate during care. He follows simple commands. His movements are slow and cautious. Mr. Kane does not appear to be in pain. His skin is warm and dry. He has bruises on his left forehead, shoulder, and hip areas, probably as a result of falling. He was dehydrated on admission and has an intravenous line in place. Mr. Kane demonstrated dysphagia (difficulty swallowing). A swallow function test (lateral video fluoroscopic observation) revealed abnormalities in swallowing. The unit’s interprofessional stroke care team meet to plan a comprehensive care plan for Mr. Kane. In addition to the professionals on the team, Mr. Kane’s son, his daughter-in-law, and their two college-aged children come to visit each day and want to be involved in his care. The team’s goal is to return Mr. Kane to his maximum level of independent functioning.

Discussion Questions

1. List the members of the group of professionals and others, including Mr. Kane and his family, who should be represented on the stroke care team.
2. Identify at least one specific team goal for Mr. Kane’s care. Explain how team members will use their complementary roles and responsibilities, collaboratively, to achieve this goal.

1. Members of the Stroke Care Team: a. Physicians: Neurologist, Hospitalist, and possibly a Physiatrist (rehabilitation medicine specialist). b. Nurses: Registered Nurses (RNs) for acute care and specialized stroke nurses for rehabilitation. c. Physical Therapist: To work on Mr. Kane’s mobility and help regain function on his right side. d. Occupational Therapist: To assist with activities of daily living (ADLs) and adapt Mr. Kane’s living environment. e. Speech-Language Pathologist: To address his dysphagia and communication difficulties. f. Social Worker: To assess Mr. Kane’s psychosocial needs, including potential changes in living arrangements. g. Dietitian: To provide appropriate nutrition considering Mr. Kane’s swallowing difficulties. h. Case Manager: To coordinate care, plan for discharge, and ensure continuity of care. i. Pharmacist: To manage medications and prevent potential drug interactions. j. Rehabilitation Technician/Assistant: To support therapy sessions. k. Mr. Kane (patient) and his family (son, daughter-in-law, and college-aged children).
2. Team Goal: The primary goal of the stroke care team is to maximize Mr. Kane’s independence and quality of life post-stroke. This includes regaining as much function as possible in his right side, improving his communication abilities, addressing dysphagia, and ensuring his safety.

   Team Collaboration:

   • Physicians will diagnose and medically manage Mr. Kane’s condition, including medications and treatment plans.
   • Nurses will provide direct patient care, monitor vital signs, administer medications, and educate Mr. Kane and his family on stroke management.
   • Physical Therapists will work on improving Mr. Kane’s mobility and strength on the right side, facilitating safe transfers and ambulation.
   • Occupational Therapists will focus on activities of daily living (ADLs), adaptive techniques, and home modifications.
   • Speech-Language Pathologists will assess and provide therapy for dysphagia and communication difficulties.
   • Social Workers will evaluate psychosocial needs, assist with discharge planning, and offer support resources.
   • Dietitians will ensure proper nutrition, considering Mr. Kane’s swallowing issues.
   • Case Managers will coordinate the efforts of all team members, create a seamless transition plan for discharge, and liaise with community resources.
   • Pharmacists will oversee medication management and educate Mr. Kane and his family about potential side effects.
   • Rehabilitation Technicians/Assistants will support therapy sessions and exercises.
   • Mr. Kane and his family will actively participate in care decisions, provide input on Mr. Kane’s preferences and needs, and learn how to assist him effectively at home.

Collaboration among these professionals and active involvement of Mr. Kane and his family will ensure a comprehensive approach to his care, addressing both his medical and psychosocial needs, with the ultimate goal of optimizing his independence and quality of life.