Coordinating Care for a Patient with Osteoporosis: A Case Study

Mary, a 35-year-old African American woman, attended the clinic for her annual family planning check-up. After reporting a painful back and femur, diagnostic tests revealed she had osteoporosis. A coordinated service approach was taken to transfer her to a rehabilitation center for strength and gait training. The transition was coordinated by the author, who also assessed Mary's condition on a weekly basis to determine the effectiveness of the nursing intervention.

Question 9
To provide the best healthcare service is necessary to ensure that the most suitable and
appropriate healthcare is provided in line with an individual’s needs and or condition.
Variations in a person’s health care needs may relate to a change in their condition or
other circumstances, or even changes in their life and other conditions.
Provide an example of where you have responded to a variation in a person’s health care
needs, and how you were involved in assisting them through a coordinated service
approach?
Mary, a 35-year African American woman, attended the clinic for her annual family
planning check-up. She was using a diaphragm, and each year she would visit the setting for
follow-up care. On this particular day, Mary looks exhausted, in pain, and has a troop-like
posture. When asked what the problem was, she reported a painful back and femur, and that no
amount of time could fully restore. Also, she reported she had been falling more often, in the last
couple of months but she did not think much about. After conducting diagnostic tests, the results
showed that Mary had osteoporosis.
The nurse practitioner recommended Mary be transferred to a rehabilitation center because she
had a slightly fractured hip which would recover with time. She needed strength and gait training
to facilitate recovery of the bone. The nurse practitioner, Mary, and I started planning her
recovery plan and I was assigned to coordinate the transition. Mary would provide information
on which forms of exercise or diet she could take while the nurse practitioner incorporated our
expertise of rehabilitative care into the plan.

The doctor had agreed to release Mary in a day’s time. So, I contacted the rehabilitation
center and booked Mary. I told the administrator that Mary would be reporting to the clinic the
next day with her recovery plan and possible discharge date. I would be responsible for assessing
Mary’s condition on a weekly basis to determine whether the nursing intervention was effective.
The following day, I took Mary to the rehabilitative center, guided her through the admission
process, and ensured that her environment was safe for her condition. I counterchecked the
facility’s ability to offer Mary help the needed and only left after Mary was comfortably settled
in. I promised her I would see in a week for a follow-up. According to Rich et al. (2012)
effective coordination in people with complex healthcare problems is critical for improved health
outcomes.

Reference
Rich, E., Lipson, D., Libersky, J. and Parchman, M., 2012. ‘Coordinating care for adults with
complex care needs in the patient-centered medical home: Challenges and solutions’. Rockville,
MD: Agency for Healthcare Research and Quality. Available from
https://pcmh.ahrq.gov/sites/default/files/attachments/coordinating-care-for-adults-with-complex-
care-needs-white-paper.pdf (Accessed on 17 September 2018).