Reference no: EM133219065

A 70-year-old male patient has been admitted to the hospital with complications of stage 4 congestive heart failure and is anticipated to be discharged in two days.

The life expectancy of this patient is less than six months. The patient is in denial about his diagnosis and is resistant to discuss additional resources in the home setting. The patient does not currently have a living will. The patient and spouse travelled 100 miles to the hospital; their home community is considered a healthcare professional shortage area. Patient's support systems include a spouse and two children who live locally. The patient requires oxygen and a walker to ambulate. The patient's spouse has reported that the patient is anxious about hospital bills and finances moving forward. Both the patient and the patient's spouse's primary language is Spanish, and their understanding of the English language is minimal. The patient has been hospitalized for management of congestive heart failure three times in the past 12 months. The patient's insurance is Medicare.

D. Outline the major elements of the patient/family-centered discharge plan by doing the following:

1. Identify essential strategic partners and organizational stakeholders who should participate in creating the discharge plan.

2. Identify any individualized interventions needed to meet the patient's specific needs, based on the patient's chronic illness.

3. Discuss the most appropriate engagement technique to motivate the patient's continuous adherence to the discharge plan.

4. Compile a list of resources across the healthcare continuum and explain how the resources will assist this patient in managing the chronic illness and possible end-of-life care.