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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. 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

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  1. Case scenario, Mrs X for Care Co-ordination Pip Bourke, Medical Chronic Care Coordinator based at Whitehorse Division of General Practice

  2. Case summary • Female: 56 years old • Increased difficulty in self managing • No key worker • Referral to HARP to address health issues.

  3. Case summary 10 30 16 (19+)

  4. Contributing FactorsU = urgent action; H = high importance; M = medium importance

  5. Contributing FactorsU = urgent action; H = high importance; M = medium importance

  6. Client’s perception of her problems. • Inability to decrease medications for pain without adverse effects • Relationship breakdown with son • Negative body image • Breathing difficulties

  7. The most significant immediate actions.

  8. 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

  9. Care Coordination Plan • Consistent Communication • All Parties speak the same message • Point of reference • Overlapping of services • Complexity of patient • Clear about whose role

  10. 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

  11. 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

  12. 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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