What referrals would you make to other disciplines

Reference no: EM133575946

Problem

Jimmy Jansen is a 44-year-old man with type 1 diabetes mellitus. He will be discharged from your hospital and referred to a home health agency for coordinated care management follow-up at home. He is experiencing multiple complications from his diabetes, including the recent onset of blindness and peripheral neuropathy. His left leg was amputated below the knee last year because of a gangrenous infection of his foot. He is unable to wear his prosthesis at present because he has a small ulcer at the stump site. His chart states that he has been only "intermittently compliant" with blood glucose testing or insulin administration in the past despite the visit of a community health nurse on a weekly basis over the past year. His renal function has become progressively worse over the past 6 months, and it is anticipated that he will need to begin hemodialysis soon.

His social history reveals that he recently separated from his wife and has no contact with an adult son who lives in another state. He has not worked for more than 10 years and has no insurance other than Medicaid. The home he lives in is small, and he says that he has not been able to maintain it with his wife gone. No formal safety assessment of his home has been conducted. He also acknowledges that he is not eating right because he now must do his own cooking. He cannot drive and states, "I don't know how I'm going to get to the clinic to have my blood cleaned by the kidney machine."

Task

Mr. Jansen has many problems that would likely benefit from coordinated care management intervention. Use the attached template to create a coordination of care plan. Upload your completed plan with a cover page and a reference page for any sources used, by Sunday 10:59 pm to the dropbox. (As you type in the template it will expand as needed) Use in-text citations to support your thoughts

A. Make a list of five problems requiring care coordination for Mr. Jansen that you would use to prioritize your interventions.

B. Then make a list of at least five goals that you would like to accomplish in planning Mr. Jansen's coordinated care. Make sure that these goals reflect realistic patient outcomes.

C. What referrals would you make to other disciplines and or providers, and for what interventions ? What interventions would you implement yourself?

D. What is your plan for follow-up and evaluation?

Reference no: EM133575946

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