Running head: SHARED CARE PLANS 1

Shared Care Plans

Name

Institutional Affiliation
SHARED CARE PLANS 2

Shared Care Plans

Question 1: Patient Care Team

The patient care team comprises various elements that interact to achieve Liam's

treatment. In this section, we will look at multiple facilities, organizations, professionals, and

the parents as they all interact to achieve Liam's treatment. We will also look into the primary

and secondary elements of care as well as the relevant referral process. (Australia, 2016)

First is the facilities. Westtown Regional A&E department where Liam has frequently

attended. Which includes four times last summer, including an overnight admission due to

exacerbation of Asthma. We also have the Rural service center 250 km away from Westtown,

where Liam's regular Pediatrician is located. The Youbeaut clinic which came up through the

merging of local practice, and Dr. Jones, who is Liam's doctor. Last but not least is in

Sydney, which is located 500 km away, where his regular pediatric rheumatologist is situated.

Various professionals also attend Liam. We have Dr. Jones, who is Liam's doctor in

Westtown, the regular Pediatrician who reviews his Asthma Action Plan, a Radiologist who

performed an MRI for Liam, a Pharmacist for the correct administration of required drugs, a

Physiotherapist for his local fortnightly physiotherapy back in mixed farming property 25km

from Westtown, where his mother and stepfather live, Registered nurses/ Nurses who take

care of him while admitted and work on his nursing care plan. Also, we have the pediatric

rheumatologist in Sydney, which is located 500 km away, the Counsellor who assists him in

coping with the challenges he is facing.

Primary elements of care. It is the initial and generalized stop for medical concerns

and symptoms. In this case, it includes Liam's family and Dr. Jones. Dr. Jones owns a clinic

near his home town and receives Liam in case of any symptoms and referrer him to other

specialists for further reviewing. His parents and step-parents also play a crucial role in

primary health care. For instance, his father, Michael, and mother Erica take up the
SHARED CARE PLANS 3

responsibilities of transporting Loma for the multiple medical appointments and therapy

sessions (Mulvale, Miatello, & Hackett, 2016). This includes a monthly medical appointment

in Sydney, local fortnightly physiotherapy, GP appointments as required, and paediatrician

appointment quarterly. Erica continually shows concern to his son's behaviors and is hopeful

that in participating in the Healthcare Homes Program will assist in better management of

Liam. (McCarthy, 2015)

Secondary elements of care. The aspects show that one will be taken care of with

great consideration of an individual who has expertise in that field. Specialists in Liam's case

include the pediatric rheumatologist whom Dr. Jones had referred to for further review as he

is ailing from Juvenile Idiopathic Arthritis. Further, he has to attend an appointment on his

regular Pediatrician to review the Asthma Action Plan. (Brown, 2020)

The referral of Liam from Dr. Jones (the general practitioner) to a specialist is quite

essential for the management of Liam's condition. Liam is referred to a paediatrician to tackle

on proper and effective management of Asthma. He is further directed to a pediatric

rheumatologist for effective and efficient management of Juvenile Idiopathic Arthritis. An

effective referral process ensures Liam receives the best possible care closest to home. It also

ensures Liam receives optimal care. It is an essential process in the healthcare system. In that

manner, the aspect is taken to be the critical component of requirement and quality clinical

care Contributes to high standards of care in the manner that it improves patient outcome for

Liam. In conclusion, the various stakeholders in Liam's care all interact to achieve the best

possible outcome for his treatment.

Question 2: Patients barriers to care goals

Liam's care goals include; addressing Liam's psychological health, getting to the

bottom of the Asthma and JIA causes that have called worse over the past six months, better

management, and organization of appointments and information. Liam would also love to be

expected, like every other kid, and be playing during the weekends. With this care goals

come various barriers that affect the implementation of the plans.

The first barrier is on situational complexity. Here, we have activity limitations or

participation restrictions (Edemekong, Bomgaars, Sukumaran, & Levy, 2020). Liam is

limited from participating in sports activities during the weekend due to the JIA; thus, the

activities of daily life are affected. Assessment of activities aids the health care provider in

determining whether or not Liam requires further rehabilitation. Liam's treatment outcome

can also be assessed from the actions he can perform, for example, playing sports over the

weekend.

The second barrier to Liam's care goals is system complexity. Intra- and inter-service

fragmentation is playing out. Liam’s medical appointments are fragmented, as he has to

travel 500km away to Sydney for a check-up with his regular pediatric rheumatologist. He

also has to travel 250km to see his Pediatrician. With all this fragmentation of services,

there's the risk of mismanagement of information received from the various medical

appointments. Thus, with the fragmentation of care, Liam could miss out on a piece of

information that would affect his health status due to the ineffectiveness that comes with the

fragmentation of care.

The third barrier to achieving Liam's care goals majors in medical complexity. The

psychological well being of Liam is affected by the illness that he is experiencing. There is a

higher rate of experiencing social problems, aggressive behaviors, somatic complaints,

anxiety, and depression. Liam's mother complains that she is worried about her son’s
SHARED CARE PLANS 5

psychological well being as soon as possible. Thus, children like Liam, who suffer from

chronic conditions, have a higher rate of externalizing and internalizing problems. This could

interfere with behavioral, social, and thought abilities, which subsequently affects their care

indirectly. (Memari, Chamanara, Ziaee, & Kordi, 2016). In conclusion, situational, medical,

and system complexities contribute to barriers that affect the delivery of care, like in the case

of Liam.

Question 3: Care Coordination.

With Liam's chronic condition it necessitates having a registered nurse who will be

able to manage his shared care plan effectively. We are going to identify some of the skills

required by the nurse as well as how those concepts of skills relate to Liam's care plans and

the barriers to care.

One of the skills that a registered nurse requires is the ability to liaise and work

between and across various agencies and partners (Soars & Gallagher, 2020). Liam has to see

multiple specialists, including the pediatric rheumatologist in Sydney, his Pediatrician to

check on his Asthma, and Dr. John, who checks up on him now and then. The nurse should

be able to work with the three Doctors in coordinating Liam's care. The nurse should also be

able to have clinical management skills, especially for long-term conditions, as the Juvenile

Idiopathic Arthritis that Liam has. This will enable the nurse to walk with the patient through

the various stages of the illness. The nurse should also be able to manage an interplay of

diseases that occur in the course of the long-term (Busetto, 2016). In Liam's case, the nurse

should be able to manage both the Asthma as well as take caution on the broken bone.

(Harrison, Henderson, Miller, & Britt, 2016)

Medicine management is another essential skill the nurse requires in the management

of Liam (Sutcliffe, Jasper, & Hughes, 2018). He is on Naproxen 250mg twice daily,

paracetamol PRN for pain, inhaled corticosteroid daily, and Salbutamol PRN. Thus, the nurse
SHARED CARE PLANS 6

should be able to monitor the drug uptake by Liam to ensure he takes the right dose at the

right time. The registered nurse should be able to work in home and community settings

(Wallace, Salisbury, & Lewis, 2015). This will enable Liam to get the necessary care he

requires even when he is at home.

The registered nurse should also be able to have good communication skills

(Foundation, 2019). With good communication skills, the nurse can be able to convey

empathy to Liam as well as to his parents. With good communication skills, the nurse can be

able to get vital information to the parents regarding his condition ranging from the

symptoms to the prognosis. Last but not the least, the nurse should have skills in supporting

and promoting the well-being of the patient (van Deventer, Robert, & Wright, 2016). In this

case, the nurse should promote well being by encouraging Liam to avoid the allergens, take a

well-balanced diet, drink plenty of fluids as well as encouraging him to take part in exercises

that will not exacerbate the already underlying condition.

Having a nurse who can be able to liaise with the various doctors, he/she can be able

to organize and manage the doctor’s appointments in an organized manner and be able to

utilize the information that will be received in a manner that will be of benefit to Liam. A

nurse who has the skill of promoting well-being will be able to regularly advise Liam on

ways and importance of avoiding allergens- dust and pollen- as they will exacerbate his

condition.

In conclusion, the nurse needs to have some skills in care coordination. The gifts will

go a long way in promoting Liam's care goals. Also, having such skills enables the nurse to

find ways of maneuvering against some of the barriers that might hinder the achievement of

care goals.

Question 4: Complex Innovation of Care

Use of technology such as telehealth and eHealth records for more accessible

communication between all relevant specialists who manage Liam. Research involves

multidisciplinary and involves Liam's management actively. Improve Liam's literacy on

health (e-health) management so that he can independently manage himself with minimal

assistance or parental supervision. Through an online virtual learning network educating the

health workforce and organizational learning is achieved through them. (Kuipers, Kendall, &

Barber, 2011)

Partnership, collaboration, and teamwork among the multidisciplinary team,

organizations, and different sectors are recommended for Liam's monthly case conferences

for every two months (WHO, 2020). The collaboration described is co-operation amongst

other healthcare practitioners from different places. The matter entails shared objectives,

collective ownership, mutual responsibility, as well as shared decision making among the

various doctors attending to Liam. It is mostly associated with timely and more responsive

service of Liam requiring complex care needs. (Panagioti, Bower, & Kontopantelis, 2016)

Furthermore, it improves access to a better information exchanges between different

teams that attend to him. Liam's family also require more support when they transition before

different phases of their conditions and other specialists' groups. (Austria Institute of Health

and Welfare, 2018)

In Liam's health system, the health workers managing him should create a culture,

association, and contrivances that promote safe, excellent care for his management.

Mobilization of family resources is essential to meet the needs of Liam (Blumenthal,

Chernof, Fulmer, Lumpkin, & Selberg, 2016). They are empowering Liam to manage health

and his condition through self-management support and organizing Liam's and population

data to facilitate an effective care through clinical information systems. Assuring Liam, the

delivery is effective, efficient clinical care and self-management support through delivery
SHARED CARE PLANS 8

system design. Decision supporting by promoting clinical care that is consistent with

scientific evidence and patient preferences. (Miller, Bowen, Diefenbach, & Tercyak, 2018)

Education of Liam's health workforce for effective management through case-based

discussion rather than concept-based discussion, which is more beneficial (Clarke, Bourn,

Skoufalos, Beck, & Castillo, 2017). The problem-solving capacity of Liam's health care team

can be further improved through proficiency training, which dwells on teamwork, awareness,

collaboration, encouragement, and appreciation of other members' styles. Using case-based

learning: community providers learn from specialists, and from each other, and specialists

also learn from community providers. All this would assist in identifying delivery goals in

Liam's shared care plan (Hayes, Salzberg, McCarthy, Radley, & Abrams, 2016). In

conclusion, various innovations, programs, and technology assist in delivering the goals

identified in Liam's shared plan.

References

Gorin, S., Haggstrom, D., Han, P., & Fairfield, K. (2017). Cancer care coordination:

Asystematic review and meta-analysis of over 30years of empirical studies. Ann

Behav Med, 51(4), 532–546.

Australia, N. a. (2016). Registered Nurses Standards for Practice.

Austria Institute of Health and Welfare. (2018). Austrias Health 2018: Chapter 4.2 Social

deerminants of Health Austrias Health series no. 16. Canberra.

Blumenthal, D., Chernof, B., Fulmer, T., Lumpkin, J., & Selberg, J. (2016). Caring forhigh-

need, high-costpatients – Anurgentpriority. Engl j Med, 375(10), 909–911.

Brown, D. E. (2020). Lewis's Medical-surgical Nursing : Assessment and Management of

Clinical Problems, Fifth ed. Elsevier Australia: Chatswood NSW. .

Busetto, L. (2016). The implementation of integrated care and its contribution to improved

outcomes for people with chronic conditions. International journal of integrated

care., 16(4).

Clarke, J. L., Bourn, S., Skoufalos, A., Beck, E. H., & Castillo, D. J. (2017). An Innovative

Approach to Health Care Delivery for Patients with Chronic Conditions. Population

Health Management, 20(1), 23-30.

Edemekong, P. F., Bomgaars, D. L., Sukumaran, S., & Levy, S. B. (2020). Activities of Daily

Living (ADLs). STATPEARLS.

Foundation, T. P. (2019). Experience-based co-design toolkit.

Harrison, C., Henderson, J., Miller , G., & Britt, H. (2016). The prevalence of complex

multimorbidity in Australia. Australian and New Zealand journal of public health,

40(3), 239-244.

Hayes, S., Salzberg, C., McCarthy, D., Radley, D., & Abrams, M. (2016). High-Need, High-

Cost Patients: Who Are They and How Do They Use Health Care? A Population-
SHARED CARE PLANS 10

Based Comparison of Demographics, Health Care Use, and Expenditures. Issue Brief.

Commonwealth Fund, 1-4.

Kuipers, P., Kendall, E., & Barber , L. (2011). Complexity and Healthcare: Health

Practitioner workforce, services, roles, skills, and raining to respond to patients with

complex needs. Brisbane: Clinical Education and Training Queensland.

McCarthy. (2015). Models of care for high-need, high-cost patients: an evidence synthesis.

Issue brief (Commonwealth Fund), 31 (1–19). in Australian Department of Health

(DoH). (2016) Primary Health Care Advisory Group Final Report.

Memari, A. H., Chamanara, E., Ziaee, V., & Kordi, R. (2016). Behavioral Problems in

Juvenile Idiopathic Arthritis: A Controlled Study to Examine the Risk of

Psychopathology in a Chronic Pediatric Disorder. International Journal of Chronic

Diseases.

Miller, S., Bowen, D., Diefenbach, M., & Tercyak, K. (2018). A research agenda for care

coordination for chronic conditions: aligning implementation, technology, and policy

strategies. Translational Behavioral Medicine, 8(3), 515-521.

Mulvale , A., Miatello, A., & Hackett, C. (2016). Applying experience-based co-design with

vulnerable populations: Lessons from a systematic review of methods to involve

patients, families and service providers in child and youth mental health service

improvement. Patient Experience Journal, 3(1), 117-129.

Panagioti, M., Bower, P., & Kontopantelis, E. (2016). Association

betweenchronicphysicalconditions and the effectiveness of collaborativecare for

depression: An individual participant data meta-analysis. jama Psychiatry, 73(9),

978–989.

Soars, L., & Gallagher, R. (2020). Chronic illness and complex care (5TH ed.). Elsevier:

Chatswood NSW.
SHARED CARE PLANS 11

Sutcliffe, C., Jasper, R., & Hughes, J. (2018). Care coordination in adult social care:

Exploring service characteristics within the non-statutory sector in England. Journal

of Social Work., 18(5), 5001-524.

van Deventer, C., Robert, G., & Wright , A. (2016). Improving childhood nutrition and

wellness in South Africa: involving mothers/caregivers of malnourished or HIV

positive children and health care workers as co-designers to enhance a local quality

improvement intervention. BMC health services research., 16(1), 358.

Wallace, E., Salisbury, C., & Lewis, C. (2015). Managing patients with multimorbidity in

primary care. Bmj, 350.

WHO. (2020). Protecting workers Health.