Home Health Care and Rehabilitation Therapy During care coordination and

Home Health Care and Rehabilitation Therapy During care coordination and transition of care planning, it is important to consider the type and level of care a patient might need. You are the transitional care manager assigned to Mr. Smith prior to discharge. Based on Mr. Smith’s assessment findings, develop a discharge plan that encompasses his care needs following discharge. Discuss three to five interdisciplinary roles that will be essential in supporting Mr. Smith’s home health and rehabilitative care needs. You are the home health nurse assigned to treat Mr. Smith. Identify two areas of concern that you might prioritize during your initial visit with him following discharge. Psychosocial and Spiritual Considerations Providing holistic nursing care for patients with complex conditions requires that the nurse takes into account the patient’s psychosocial and spiritual needs. Given the patient’s current situation, discuss ways in which the nurse can take into account and address the patient’s psychosocial and spiritual needs. Just Culture The patient is due to receive his IV antibiotic prior to discharge. As the nurse reviews the electronic orders, she notices that the antibiotic dose seems incorrect. Upon discussion with the provider and pharmacy, it is determined the dose entered was incorrect. Discuss how reporting this near miss will help contribute to a just culture reflecting civility and respect. Discuss how clinical judgement and critical thinking should be applied despite the use of information and communication technologies. Levels of Risk As Mr. Smith is waiting for the nurse, he becomes impatient and starts to verbally attack the patient care technician as she obtains his vital signs. Identify actual and potential levels of risk to the care team within this situation given the patient’s history of PTSD. What can the nurse do to diffuse this situation? What steps can be put in place to ensure safety for both patients and providers in the future? Patient Portal The nurse is helping Mr. Smith log in to the Patient Portal (i.e. MyChart) before discharge. Explain the considerations for ensuring the patient would be able to use this resource at home. In your discussion include considerations related to the patient’s condition and cognitive status based on his assessment findings and history of injury reviewed in previous topics. Discuss the benefits for both the patient and the care team in using information and communication technology to support the patient-provider relationship. What obstacles might hinder his use of the Patient Portal? Telehealth Mr. Smith is scheduled for a telehealth appointment with the psychiatrist upon discharge. Discuss the information and resources that the nurse should ensure the patient has available in preparation for his visit. References (Please include working hyperlinks.)

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