Pain Management Case Plan Implementation
Implementation is the next important step after completing the preliminary care coordination plan for Mr. John, the 45-year-old man with chronic pain after an accident. The implementation is critical to ensure the continuum of care from the hospital to home, and to ensure that Mr John lives a quality life without regular visits to the hospital. The process involves the use of the identified community resources, the local pharmacy, and an organization that provides home-based care and therapy, to coordinate and support his care. The case manager will also ensure ethical considerations, prevent policy issues, observe cultural norms and safety, as well as the physiological needs of the patient. Therefore, the nurse will provide constant communication with the other care providers involved in the case, including the pharmacist and the therapist, to ensure that the treatment proceeds according to the plan. The coordination is necessary to create a safe environment for the patient. Although nurses can provide adequate care at the hospital, a transition is essential and require seamless coordination of care between the case manager and community resources to promote healing and improve the quality of life of the patient.
Patient-Centered Health Interventions and Timelines
The implementation of the preliminary care coordination plan involves service delivery outside the hospital, and within the community. However, the case manager will remain actively involved in the care delivery process. Therefore, although the patient will receive care outside the hospital setting, physician interaction with him will remain critical to ensure faster healing and improve his quality of life. The nurse will use social communication tools, such as WhatsApp, a pain management app (PAIN COMPANION, which helps the patient to log in their pain and learn exacerbating, and alleviating factors), and the phone to communicate regularly with the patient and his primary caregivers. For example, the nurse will call the therapist and the patient after every therapy session to monitor the progress. The patient will have therapy sessions twice every week. The coordination will improve the care outcomes for the patient.
Another important consideration will be on the medication that the patient will be using. The nurse will coordinate with the pharmacist providing the drugs to ensure that the patient receives the right medication and dosage (Kern, Edwards, & Kaushal, 2014). She will keep track of the medication usage and advice accordingly. She will ensure that the patient obtains drugs from the pharmacist before completing the current order to prevent running out of critical medications. Besides, the nurse will ensure that the patient visits the hospital weekly to monitor progress and establish the plan for the coming week. Regular interaction with the nurse will inform the success of the coordinated care plan.
Ethical Considerations
The case managers should make various ethical considerations to ensure that the patient receives safe care out of the hospital and when he visits the facility for review. The patient-centered medical home (PCMH) plan is a necessary process that help reduce the cost to the patient and the health care organization, as patents continue receiving necessary care while at home. However, the plan should be aligned with medical ethics principles and respect the values and beliefs of the patient (Glowacki, 2015). Patient choice, autonomy, or independence is one of the considerations that the case manager should make. Therefore when receiving care outside the hospital, various challenges confront the case manager, including the importance of respecting his beliefs, which might hinder the recovery process. Although some cultural practices, such as the religious belief that prevent the use of medical interventions, could affect the recovery process, the case manager should respect them (Kern, Edwards, & Kaushal, 2014). However, the nurse should advise the patient and get informed consent any time she wants to implement a new intervention. Generally, the nurse will ensure patient-centeredness in working with the patient, and his family professionally, respecting his autonomy and the right to make decisions affecting his care.
Health Policy Implications for the Coordination and Continuum of Care
The health care providers should operate within the tenets of complying with governmental and organizational policies when interacting with their patients. The coordinated care plan will operate within the triple aim of the healthcare system in the United States, which is to improve the care experience, improve the health of populations, and reduce health care costs (Nielsen et al., 2014). The framework has changed the way health care delivery occurs in the country. The coordinated care plan will focus on improving the care experience for Mr. John, including helping him to manage the pain out of the hospital. It will also improve his health and that of a similar patient population, that is, those suffering from chronic pain. The nurse managing his case recognizes that retaining the client at the hospital will be expensive for the family and the hospital in general. Therefore, the coordinated care plan will achieve the aim of reducing the cost of health in the country by supporting out of hospital care for patients, such as Mr. John, whose disease can be managed at home. The use of community resources will help to overcome the increasing burden of care within the US healthcare system.
Another policy related to the care coordination plan is Healthy People 2020. One of the facets of the system is “Self-Management Education: The Chronic Disease Self-Management Program.” The policy requirement is recommended for individuals with chronic illnesses to support them deal with the conditions through cost-effective mechanisms, such as self-care. Thus, the role of the case manager is to educate the patient on how to manage the chronic pain through the appropriate use of medications, therapy, effective communication, and nutrition (Smith et al., 2017). The case manager will educate the patient and his family regarding self-management for better outcomes.
Key Strategies and Recommendations
The implementation of the care coordination process in the treatment of Mr. John will take advantage of some of the standard strategies to build a useful care coordination model. First, the case manager will use the patient-centered coordination model that places the individual at the center of the process. The model will focus on the medical and non-medical needs of the patient, such as the need for medication, and to ensure his positive psychological wellbeing. The model requires the nurse to work closely with the patient and his caregiver to meet the needs. The coordination process begins when the nurse is developing the care plan to intervene early and prevent problems from worsening. Another critical strategy and recommendation will be providing continuity of medical and non-medical services. For example, the case manager should ensure that the patient has an environment and community resources that are adequate to support the healing process (Kern, Edwards, & Kaushal, 2014). For example, the patient’s home should have necessary accommodations, such as a comfortable place to sleep, and safe for the patent to walk around.
The model should draw from multiple dimensions of a system of care that affect the wellbeing and health of the patient. Another essential strategy is implementing tools for delivering care, such as communication devices to communicate timely, and accurate information between the case manager and the patient (and caregiver) and electronic health records (EHRs) for monitoring and tracking patient care (Kern, Edwards, & Kaushal, 2014). Finally, the case manager should have a plan to assess the patient to establish the effectiveness of the care plan and the extent to which they have achieved objectives. The results of the assessment inform possible changes, for example, if the current plan fails to meet any of the goals, it will inform a revision to improve the plan for future improvement of patient care. The strategies will help the case manager to work with the patient and the caregiver to help him heal from the pain and psychological impact of his illness.
Conclusion
The care coordination plan aims at helping Mr. John to recover from the chronic pain he experiences following the accident. Research affirms that coordinated care plans promote patient outcomes and satisfaction if implemented correctly. Therefore, proper implementation of the preliminary care, and coordination plan for Mr. John will help him to overcome the pain and improve his quality of life. The case manager will work with the patient, his family, and community care providers to improve the outcome of the patient. She will train and maintain regular communication with the patient about the self-care plan.
References
Glowacki, D. (2015). Effective pain management and improvements in patients’ outcomes and satisfaction. Critical Care Nurse, 35(3), 33-41. https://doi.org/10.4037/ccn2015440
Kern, L. M., Edwards, A., & Kaushal, R. (2014). The patient-centered medical home, electronic health records, and quality of care. Annals of Internal Medicine, 160(11), 741-749 DOI: 10.7326/M13-1798
Nielsen, M., Buelt, L., Patel, K., Nichols, L. M., & Fund, M. M. (2014). The patient-centered medical home’s impact on cost and quality. Annual Review of Evidence, 2015, 202014-2015. Retrieved from https://www.pcpcc.org/sites/default/files/resources/The%20Patient-Centered%20Medical%20Home’s%20Impact%20on%20Cost%20and%20Quality,%20Annual%20Review%20of%20Evidence,%202014-2015.pdf
Smith, M. L., Towne, S. D., Herrera-Venson, A., Cameron, K., Kulinski, K. P., Lorig, K., … & Ory, M. G. (2017). Dissemination of chronic disease self-management education (CDSME) programs in the United States: intervention delivery by rurality. International Journal of Environmental Research and Public Health, 14(6), 638. Retrieved from https://www.mdpi.com/1660-4601/14/6/638
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