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Case scenario, Mrs X for Care Co-ordination. Pip Bourke, Medical Chronic Care Coordinator based at Whitehorse Division of General Practice. Case summary. Female: 56 years old Increased difficulty in self managing No key worker Referral to HARP to address health issues. Case summary. 10.

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Case scenario mrs x for care co ordination

Case scenario, Mrs X for Care Co-ordination

Pip Bourke, Medical Chronic Care Coordinator

based at

Whitehorse Division of General Practice


Case summary
Case summary

  • Female: 56 years old

  • Increased difficulty in self managing

  • No key worker

  • Referral to HARP to address health issues.


Case summary1
Case summary

10

30

16 (19+)


Contributing factors u urgent action h high importance m medium importance
Contributing FactorsU = urgent action; H = high importance; M = medium importance


Contributing factors u urgent action h high importance m medium importance1
Contributing FactorsU = urgent action; H = high importance; M = medium importance


Client s perception of her problems
Client’s perception of her problems.

  • Inability to decrease medications for pain without adverse effects

  • Relationship breakdown with son

  • Negative body image

  • Breathing difficulties



Complex needs identified
COMPLEX NEEDS IDENTIFIED

  • Health issues

  • Social issues

  • Cognitive issues

  • Vulnerable (in living situation)

  • No effective support from family or friends

  • Difficult behaviours

  • Does not recognise need for assistance

  • Frequently changing and fluctuating needs

  • Communication/relationship problems

  • Acute decline in ability to self-manage


Care coordination plan
Care Coordination Plan

  • Consistent Communication

  • All Parties speak the same message

  • Point of reference

  • Overlapping of services

  • Complexity of patient

  • Clear about whose role


Services involved in this episode
SERVICES INVOLVED IN THIS EPISODE

  • Local GP

  • Council HACC services

  • Rehab in the Home – Physio, Dietitian, Occupational Therapy

  • HARP Medical Chronic Stream

  • HARP Aged Care Stream

  • Complex Care clinic

  • Outpatients

  • Pharmacy

  • State Trustees

  • Phone Counselling -Community Health Service

  • RDNS

  • Oxygen suppliers

  • Coles meals

  • MeQWA alarm

  • Ambulance Service – Transport

  • Hair Dresser


Complex needs identified comparison mrs s and mrs x
COMPLEX NEEDS IDENTIFIEDComparison Mrs S and Mrs X

  • Health issues

  • Social issues

  • Cognitive issues

  • Vulnerable (in living situation)

  • No effective support from family or friends

  • Difficult behaviours

  • Does not recognise need for assistance

  • Frequently changing and fluctuating needs

  • Communication/relationship problems

  • Acute decline in ability to self-manage

  • Police Problems


Care coordination plan questions
Care Coordination PlanQUESTIONS

  • Who is the Care Coordination Plan for?

  • Is it the paper of the verbal communication?

  • Which service provides the Key Worker?

  • Patient ownership and privacy?????


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