Submit an 8- to 10-slide narrated PowerPoint in which you present the case and plan to the patient, family, and IDT in a culturally competent manner

Submit an 8- to 10-slide narrated PowerPoint in which you present the case and plan to the patient, family, and IDT in a culturally competent manner.

Describe the new, revised care plan that incorporates cultural factors and aspects of health:

Two identified problems

Three or four goals

Three or four interventions

Identify and explain at least one opportunity for another discipline (not currently a member of the IDT) to collaborate in care.

Describe plans for discharge or transition, taking into account the patient’s wishes and cultural considerations.

Requirements: 8-10 slides

Care Plan: Mr. Wilson

Arieal Jones

Master of Social Work: Walden University

SOCW 6206: Interdisciplinary Healthcare Practice

Dr. Harper

July 16, 2023

Mr. Wilson’s Care Plan

Identified Problems:

Risk of falls and injury due to Mr. Wilson’s dementia and impaired mobility.

Poor management of diabetes leads to uncontrolled blood sugar levels and potential complications.

Housing stability and if Mr. Wilson goes to his daughter’s house.

Goals:

Reduce the risk of falls and promote safety for Mr. Wilson.

Improve diabetes management and maintain stable blood sugar levels.

Enhance Mr. Wilson’s overall quality of life and well-being.

Mr. Wilson needs assistance organizing his medications, appointments, and daily tasks.

Social services can assist Mr. Wilson in finding in-home and community-based programs to retain his independence as long as possible.

Interventions:

Fall Prevention:

Conduct a comprehensive assessment of Mr. Wilson’s home environment to identify and address potential fall hazards. This will be done by Implementing safety measures such as installing grab bars, removing clutter, and ensuring adequate lighting. Furthermore, provide Mr. Wilson with assistive devices like a walker or cane to improve mobility and stability. We can also educate Mr. Wilson and his caregiver on fall prevention strategies, including proper body mechanics and exercises to improve balance (Donnelly et al., 2018).

Diabetes Management:

Collaborate with a registered dietitian to develop a personalized meal plan for balanced nutrition and blood sugar control. This will also include assisting Mr. Wilson in monitoring his blood sugar levels regularly and providing education on proper medication management. Encourage regular physical activity tailored to Mr. Wilson’s abilities and preferences, with Encourage regular physical activity tailored to Mr. Wilson’s skills and priorities, with a focus on exercises that strengthen the heart and aid in controlling blood sugar. Then we can facilitate regular follow-up appointments with Mr. Wilson’s healthcare team to monitor his diabetes management, adjust medications if necessary, and provide ongoing education and support.

Cognitive Stimulation Therapy

Cognitive stimulation therapy (CST) is an evidence-based intervention for people with dementia (PwD) that improves cognitive functioning, social interaction, communication, and quality of life (Cove et al., 2014). This will help improve his quality of life and provide for him and his caregivers because it will improve his social communication and cognitive function overall. The objective was to enhance the interactions between the caregiver and the person they care for in their home environment so that caregivers felt empowered and could support the experience of the CST group for the person cared for.

Justification for the Care Plan:

This care plan is appropriate for Mr. Wilson because it addresses the two identified problems: fall risk and poor diabetes management. By implementing fall prevention strategies, Mr. Wilson’s safety can be enhanced, reducing the likelihood of injuries. Additionally, effective diabetes management can help prevent complications and improve his overall health and well-being.

Advocating for the Care Plan within the IDT and Achieving Buy-In:

To support this care plan, it is vital to involve all members of the Interdisciplinary Team (IDT), including the patient, caregiver, and healthcare professionals. This can be achieved through:

Open communication: Discuss with the IDT members to understand their perspectives, concerns, and goals for Mr. Wilson’s care.

Education: Provide evidence-based information to the IDT members about the importance and benefits of diabetes management and fall prevention interventions. Share relevant research and success stories to demonstrate the positive outcomes of similar care plans.

Collaborative decision-making: Involve the patient, caregiver, and other IDT members in the care planning process. Encourage active participation, listen to their input, and address any questions or concerns they may have.

Individualized approach: Tailor the care plan to meet Mr. Wilson’s specific needs, preferences, and abilities. Ensure that the interventions are realistic and feasible for him and his caregiver to implement.

Ongoing support and monitoring: Provide regular updates and progress reports to the IDT members, highlighting the positive impact of the care plan on Mr. Wilson’s health and well-being. Continuously assess and adjust the plan based on his evolving needs and goals.

By fostering a collaborative and patient-centered approach, emphasizing the benefits of the care plan, and addressing the concerns of the IDT members, buy-in and support for the plan can be achieved. Regular communication and reassurance of the positive outcomes will help maintain engagement and commitment from all involved parties.

References

Cove J, Jacobi N, Donovan H, Orrell M, Stott J, Spector A. Effectiveness of weekly cognitive

stimulation therapy for people with dementia and the additional impact of enhancing cognitive stimulation therapy with a career training program. Clin Interv Aging. 2014;9:2143-2150 https://doi.org/10.2147/CIA.S66232

Donnelly, S., Cahill, S., & O’Neill, D. (2018). Care planning meetings: Issues for policy, multi-

Disciplinary practice and patient participation. Practice: Social Work in Action, 30(1), 53–71.

Walden University, LLC. (2022). Social work case studies. [Interactive media].