Demonstrate, evaluate, and plan care coordination, case management, and transiti

by | Oct 10, 2021 | Other | 0 comments

Demonstrate, evaluate, and plan care coordination, case management, and transition services in traditional and emerging practice environments:
Case Study:
Mr. Albert King is a 68-year-old man with a grade 4 glioblastoma. He has a rapid-onset of left hemiplegia. He is being seen by home care nursing, physical therapy, and occupational therapy under the palliative care program. A craniotomy was performed to debulk the tumor. After surgery, Mr. King discharged himself home, against medical recommendations, from the rehabilitation facility that he stayed. On his arrival home, an urgent request was sent to home services to clarify his new mobility/transfer status for the home support workers (HSW). The family members were hoping for intensive in-home rehabilitation and in fact expected Mr. King to walk again. Examination revealed grade 1 to 2 strength in scattered leg muscles and a flaccid left arm. Mr. King was unable to sit unsupported. Standing pivot transfers were maximum lift × 2; therefore, the use of the mechanical lift was recommended. These findings were essentially unchanged from Mr. King’s preoperative status. The occupational therapist agreed to teach the HSW range of motion and facilitation exercises. Over the succeeding 3 months, Mr. King has been seen eight times, and there has been no motor or sensory recovery. There have been very small functional gains: Mr. King is now able to roll to his weak side in bed using the bedrail technique. Mr. King has variable wheelchair sitting tolerance (10–60 minutes at a time). Last week, Mrs. King asked about admission to a rehabilitation facility to capitalize on these gains.
1. What advice would you like to give the “circle of care” (such as Social Worker, Case Manager, Physical Therapist, Speech Pathologist, and so forth)? Underline the importance of a family meeting with all key players. Reflect on what is happening from a grief and loss perspective.
2. What are the differences among a multidisciplinary team, an interdisciplinary team, and a transdisciplinary team?

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