Care Coordination in Nursing Practice for Liam's Shared Care Plan

Nursing
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CONTENTS
INTRODUCTION...........................................................................................................................3
TASK...............................................................................................................................................3
Part one............................................................................................................................................3
1. Patient Care Team: Identify all of the facilities, organisations and professionals Liam and
his parents will have to access/interact with to achieve his treatment goals. Separate these into
primary secondary or other (if relevant) and document the referral process and their role in
Liam’s' care..................................................................................................................................3
2. Patient’s barriers to care goals: Review the patient care goals identified on the care plan.
Identify barriers for achieving the care goals..............................................................................5
Part two............................................................................................................................................6
1. Nursing practice: Outline the relevant care coordination skills you as the Registered
Nurses require to effectively manage Liam’s’ shared care plan..................................................6
2. Identify Strategies: As the complex care coordinator you have to effectively implement
Liam's’ shared care plan. Identify any/all projects, programs, technology, organisations,
innovations etc. that would assist with delivering the goals identified in Lucas’ shared care
plan..............................................................................................................................................7
CONCLUSION................................................................................................................................8
REFERENCES................................................................................................................................9
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INTRODUCTION
Care coordination within the healthcare is a deliberate organisation of care activities of
patient between two or more individuals involved in patient care in order to facilitate proper
delivery of care services (Ravelli, & et. al., (2018). This report is based on case study of Liam
who is 15 years old and suffering from asthma and Juvenile idiopathic arthritis. This report
covers information of care plan of Liam along with the role of registered nurse as complex care
coordinator to deliver shared care plan.
TASK
Part one
1. Patient Care Team: Identify all of the facilities, organisations and professionals Liam and his
parents will have to access/interact with to achieve his treatment goals. Separate these into
primary secondary or other (if relevant) and document the referral process and their role in
Liam’s' care
The provided case study is based on Liam who is a 15 years old boy and was diagnosed
with Juvenile idiopathic arthritis and asthma. He was suffering from acute exacerbation of
asthma and also has been experiencing pain associated with his juvenile idiopathic arthritis, due
to which he was admitted to the hospital overnight for one day. Three years ago, he also met with
an accident due to which his right carpel/ scaphoid got fractured. He takes medications including
salbutamol, inhaled corticosteroid preventer, paracetamol and naproxen 250 mg. As per the
provided shared care plan of Liam, his treatment goals include to be normal like everyone else
and to be able to play weekend sport again (Ravelli, & et. al., (2017). The care goal of Erica
includes to determine the strategy to address the issues from which Liam is suffering to resolve
them as soon as possible. Apart from this, her mother's goal is to determine the reason of what
has caused Liam's juvenile idiopathic arthritis and asthma to get worse over the last six months
as well as to come up with a better and effective plan for organising and managing all his
appointments and information.
The team goals in relation to Liam is to develop a plan for communication between all the
specialist and utilising electronic health record. Developing collaborative strategy for care,
fostering Liam's independent management of chronic conditions and monitoring the
effectiveness of psychological and physical interventions proximally over the next six months
are also the treatment goals of team (Cimaz, (2016). In order to accomplish these treatment
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