| Mr. Smith’s living environment should promote safety. The home environment should be free from clutter and any slippery material that would predispose him to falls. The home should have adequate lighting to minimize the risk of falls. Mr. Smith’s healthcare needs should be prioritized in the discharge process. This includes ensuring that a wound care nurse is involved in his care to provide the required wound cleaning and dressing. The nurse would also ensure that Smith’s medication needs are met. Mr. Smith’s access to mental healthcare after discharge should be maintained. This includes ensuring his close contact with the psychiatrist nurse and providing regular physical and virtual follow-up. Mr. Smith’s financial needs should be incorporated into his discharge plan. Currently, Mr. Smith does not work and lacks a source of financial support (Ghorbani et al., 2021). Therefore, the case manager should implement strategies such as providing transportation services to Mr. Smith to ease the challenges experienced in accessing his care.
Mr. Smith requires emotional support. He requires emotional support to cope with his changing functional status. Healthcare providers, social workers, support groups, and counselors should be involved in his care to ensure that he receives adequate emotional support. Mr. Smith also requires social support. He requires support from close family members, community, and community support groups for people with chronic illnesses. Mr. Smith should be linked to different social support groups for his psychosocial and emotional needs. Lastly, Mr. Smith requires medication management support. He should be educated on medication instructions such as dosage and side effects (English et al., 2022). A home health nurse should be involved to ensure his medication management needs are met. |
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| Identify two care team members who you would need to collaborate with to ensure effective coordination of care for Mr. Smith. Your response should be a minimum of 150 words. | One of the care team members that I would need to collaborate with to ensure effective care coordination for Mr. Smith is a home health nurse. A home health nurse will be required to provide the necessary care for Mr. Smith and assist him in undertaking activities of daily living. The home health nurse will provide information about how Mr. Smith is coping with his health needs. The nurse will also coordinate with other members of the care team to ensure the delivery of safe and high-quality care to Mr. Smith. The other member of the interprofessional team that would be needed for effective care coordination is a psychiatric nurse specialist. The psychiatric nurse will provide psychiatric care for Mr. Smith. The nurse will assess, plan, implement, monitor, and evaluate the effectiveness of different treatments adopted for Mr. Smith’s mental health problems. The nurse will also provide information about Smith’s mental health and needs, that will inform his treatment decisions |
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