Review the attached case study of Liam and his shared care plan then answer the following questions: Part one Complete the missing information on Liam’s care plan and provide the relevant information; Part two Role of the RN as the complex care coordinator to deliver the shared Care Plan.

Assessment 2 Shared Care Plan: Liam

Risk Level: High

Last updated by (RN) 3/3/2019

Original Author (RN). 3/3/2019

Medical Summary:

History

Liam’s has JIA (polyarticular) which was diagnosed age 8. Liam reports increasing pain levels in the joints, particularly R wrist, which was fractured in a cycling accident 3 years ago. He also reports increasing discomfort in his shoulders and knees over the last 6 months. Erica reports that prior to this latest exacerbation Liams’ symptoms have been well controlled with regular medications since his last flare up two years ago.

Liam has allergic Asthma diagnosed aged 10. His primary triggers are dust and pollen. Liam had 4x attendances at the Westtown Regional Hospital A&E department last summer. Three acute exacerbations were associated with large dust storms in the area (currently in drought) and once after being exposed to large amounts of dust while assisting his farther load cattle onto a truck in the stock yards.

Current presentation 4/4/20XX

On examination R hand, R shoulder and L knee have mild swelling and are warm to the touch. Liams complains of 4/10 pain on movement of these joints. Liam report having to use his Asthma reliever medication at least once per week for the last 2-3 months.

Liams’ mother Erica has expressed concerns in relation to his current psychological status. She states that she believes Liam is becoming increasingly socially withdrawn and is not participating as actively in the management of his JIA or Asthma as he has in the past. She states that his year advisor has also been in touch as he is displaying reduced effort in class which is out of character as he is usually a good student. Liam was somewhat reluctant to engage in discussion regarding management and treatment of either of his conditions.

Patient Care Team:

TBA

Personal Support Team:

Mother- Erica Smith

Step father- John Smith

Father- Michael Taylor

Step mother- Annie Taylor

Patient’s care goals (chronic and preventive)

Liam

• “I am sick of feeling different – I just want to be normal like everyone else”.
• “I want to be able to play weekend sport again. All the other guys in my year seem to play something on the weekends I’m the odd one out”.

Erica

• “I am very concerned about Liams’ psychological health and want to identify a strategy to address this issue ASAP”
• “We want to get to the specialists to review his JIA an Asthma management. We need to get to the bottom of what has caused his Asthma and JIA to get worse over the last 6 months”
• “We need to come up with a better plan for organizing and managing all of Liams’ appointments and the information we receive from them – we seem to just be reacting when thing go wrong these days”

Patient’s self-management tools:

• Consult paediatric rheumatologist and paediatrician ASAP.
• Develop a plan for staged increased activity and return to team sport (hockey).
• Develop strategy for competing school-based tasks when JIA/Asthma flares.
• Attend counselling/psychotherapy
• Develop a strategy for being independent at school, and home (x2) regarding medications and trigger identification (with minimal supervision).
• Erica, Michael and Liams to develop plans for medication adherence, 1-1 time and medical response plans for both households in the event of an acute exacerbation of Asthma or JIA.

Patients barriers to care goals

TBA

Team Goals: (chronic and preventive)

• Devise a plan/for communication between all relevant specialists (regardless of location) including the use of an electronic health record.
• Develop collaborative care strategy for Liams monthly case conferences (including Liam and parents) every 2 months for 6 months.
• Foster Liams’ independent management of both chronic conditions (with minimal parental supervision).
• Monitor effectiveness of physical and psychological interventions closely over the next 6 months with monthly clinic visits (care coordinator). Relevant team members to collaborate and revise plans as necessary.

 

Adapted from: Patient Centred primary Care Institute (2020) The basic person-centred care plan – Providence Medical Group Southeast, Available at: http://www.pcpci.org/sites/default/files/resources/Shared%20Care%20Plans_0.pdf