Here are some examples of for poor, better and best responses for this worksheet.
Patient or client age, gender and basic health or social information (de-identified)
59 y.o. female brought in by ambulance with shortness of breath, heart racing. Complicated by worsening pulmonary fibrosis. SHx: Lives with 2 sons. Nil stairs. Independent with personal care. Has assistance with shopping and house cleaning. Works part time in an administration role, but is finding that increasingly difficult. Recently ceased driving. On home oxygen 1LO2. Quit smoking 16 years ago. Attends pulmonary rehab.
First explain to the patient or client the purpose of this activity. Does the patient understand the concept of collaborative care?
Not initially but guessed that it meant everyone taking care of her working together in order to create best care for the patient.
I needed to explain collaborative care to the patient. The patient was OK with this as long as we really listened to what she had to say. She wanted to be included in the decisions made about her management. Additionally, the patient was hopeful that ‘nothing would be missed’ if we worked together. I hope I affirmed this for her.
Next, ask the patient/client about their experience with different professionals involved in their careover the duration of their most recent health and/or social issue. Encourage the person to tell the story in their own way with general prompts and ask for more information about their perspective on how the various professionals involved worked together in providing care.
What did the patient/client express is or was important to them when interacting with a range of professionals?
This patient/client went along with what the allied health, nursing and medical team suggestions and recommendations. She felt they worked together in order to provide her care and she was happy.
This patient felt that communication was quite good between all team members with her during the ward rounds. She talked about the importance of being part of the decision making process, especially when it was about her! She also felt it was important that she could ask staff questions about her care, particularly about aspects that impacted on how she was going to manage at home.
This patient was quite happy with the way the allied health and medical teams worked together in order to provide her care. She felt the communication was relatively good during ward rounds and that she was always included in the discussion. Most of the time there was an understanding when treating her of what the expectations were in terms of her mobility, function and current treatments and supports. It was important for this patient to be able to talk to all professionals involved in her care and be involved and informed of all changes being made. She wished at times that nursing staff took on board her daily routines in terms of medications and would implement those for her, even if that meant talking to her Doctor’s first to get the all clear as it would greatly affect her day and ability to do Physiotherapy.
What were some of the challenges expressed by the patient/client when interacting with a range of professionals involved in their care? How could these be addressed?
This patient did not always feel involved in her care. She had difficulty with her hospital medication regime because it was different to her home routine.
This patient felt at times, while she knew everyone involved in her treatment were communicating, they weren’t necessarily involving her in this especially in regards to her medications. She felt at times that she would like to know a bit more about what was going on in the discussions outside of the ward rounds. Sometimes she felt messages weren’t passed on between staff members – she was still trying to sort out her medication regime with the nurses and doctors. Input from pharmacy should also have been included in this.
This patient felt at times, while she knew everyone involved in her treatment were communicating, they weren’t necessarily involving her in this, especially in regards to her medications. Direct input from pharmacy should also have been included in her care and education of the changes to her medications. The team often talked amongst themselves after the ward round and she would have liked to be involved in that discussion as sometimes she felt decisions were made there which differed to what had been discussed with her. Potentially we should encourage able patients to ask more questions of all professionals involved in their care. She also believed at times there was a delay in the documenting of her notes as this was leading to miscommunication between the doctors and nurses as to what was expected in her treatment. It is important to then document as soon as possible after seeing the patient and to document intentions clearly, or at least discuss with team members the important points you documented as at times notes are not always available. Also, the patient was told 3 days ago that she was going to be referred to see a dietician from one of her doctors and is yet to have had them assess her. The patient believes it is important to get a visit from the dietician and would like to know when they are coming to see her. It would be important to communicate with the patient, if it is previously mentioned, that someone is coming to see her and maybe give them an estimation of when they will be coming. At home she has a regime she sticks to for the medications that she takes and in hospital this has changed for her. She asked her nurses multiple times to change this and some did while others didn’t. She understands now that this is up to her doctors (she found this out after having a conversation with them on her 7th day in the ward) but wishes the nurses could’ve guided her to ask the Doctor or tell her that this is up to them. This is where pharmacy should also be involved, as they have a role in educating patients (and staff) about medication. Therefore, we should both inform and encourage patients to ask other professionals involved in their care if we do not know the answer or even give them reasoning behind the response we have given them.
Are there other services available that could assist the patient/client? Should other professions be involved?
This patient has requested to see a dietitian as she had lost quite a bit of weight over the past month. She also reported poor energy levels and difficulty managing at home with cooking, cleaning and personal care so a referral to an Occupational Therapist would be appropriate.
The involvement of a dietitian would be useful for the patient as she reported losing weight and had a poor appetite. Unintentional weight loss is associated with poor health outcomes. The involvement of an OT would be recommended for this patient as well in terms of the facilities, home modifications and/or home-base/community supports that can be implemented that she could use if her condition worsens with each exacerbation (her functional capacity has deteriorated last admission which was in late March, as she is now not driving, and thus less independent).
How will this patient/client’s story and feelings influence your future professional practice?
I need to better understand both the patient and the roles of other team members so that I can appropriately refer the patient.
This patient’s story highlighted the importance of listening to the patient and the impact of their condition on their daily life and following through on requests made by the patient – and if this cannot be done, explain to the patient the possible reasons, rather than leaving them thinking no one cares, and if appropriate, redirecting them to someone who can answer their questions.
I think it is important to understand that each patient is different. I have also learned that my assessment of the patient is important and that from my assessment, it may be me who is the one to flag that the patient needs to be referred to the OT, dietitian or pharmacist. The patient I interviewed mentioned that this stay has been much better in terms of communication amongst the professionals in charge of treatment and discharge planning. At the same time, I understand that as a patient you want to know exactly what is going on and if one health professional is unable to answer the patient’s questions we need to redirect them to someone who can answer that question and encourage them to ask it. I also understand from this patient’s story just how significant it is to actually communicate to the other professionals who are involved in the care of a patient as it can make their stay more enjoyable and easier. This is something I will definitely make sure to implement in my future professional practice.