Meet Liam

Introduction

Liam is a 15-year-old male who lives in Westtown with his mother, Erica. Liam is a patient of Dr Jones and moved to the clinic when her practice merged with another local practice to form the Youbeaut clinic late last year.

Liam has a history of Juvenile Idiopathic Arthritis (JIA) and Asthma. Liam attended the Accident and Emergency department at the Westtown Hospital four times last summer, including one overnight admission, due to acute exacerbation of Asthma. The Westtown region has been drought declared for the last two years and is experiencing large dust storms which triggered Liam condition. Liam fractured his right hand three years ago when he fell of his bike.

In addition to his recent asthma exacerbations Liam has also been experiencing pain related to his JIA, particularly in his right wrist and right knee. Dr Jones has referred him for review with his regular paediatric rheumatologist in Sydney which is located 500km away. Liam is to have an MRI prior to attending the appointment. In light of his recent Asthma exacerbations Liam is also due to visit his regular paediatrician to review his Asthma Action Plan. His paediatrician is located in a rural service centre 250km from Westtown.

Background

Medical History

• JIA – diagnosed at the age of 8,  four joints involved
• Asthma – diagnosed at the age of 10
• Right carpel/scaphoid fracture 3 years ago (cycling accident).

Medications

• NSAIDS – BD naproxen 250mg
• Paracetamol PRN for pain.
• Inhaled corticosteroid preventer (daily)
• Salbutamol PRN

Family

Liam lives with his mother Erica (37), step father John (39) step-brother Sam (7) and step-sister Molly (4). Liam has a god relationship with Erica, John and his younger siblings however, this is a busy household with both parents working and all children attending different school/childcare facilities. John is a supervisor at the local mine. He is a shift worker and his hours include evening and weekend work.  Erica works full time at the local bank.

Liam spends alternative weekends and half his school holidays with this father, Michael (45), his step mother Annie (44) and twin step-sisters Charlotte and Grace (18 months). Michael and Annie live on a mixed farming property 25km from Westtown. Annie and Michael tried unsuccessfully to have children for several years prior to the arrival of their daughters. Charlotte and grace are very welcome additions to the family however Michael and Annie are finding the demands of caring for two young children (largely unassisted) and running the farm incredibly tiring with little-to-no spare time.

Liam has a good relationship with his father and Annie however, when he is at the farm he feels as though there is a ‘burden’ and is largely left to himself due to the time and attention required to care for the twins and run the farm.

Michael and Erica often struggle to balance the responsibilities of transporting Liam the multiple medical appointments and therapy sessions including:

• Monthly medical appointment in Sydney
• Local fortnightly physiotherapy
• GP appointments as required
• Paedtrician appointment quarterly.

Academic & Social

Liam enjoys school however, he is socially introverted and is sometimes bullied. He finds it difficult to complete school work when his hand is painful due to JIA particularly at the fracture site (Liam is right handed). Liam has one very close friend, Jack, who he has attended school with since kindergarten. Jacks and his parents recently relocated to Sydney for work.

Erica is concerned that Liam is becoming increasingly socially withdrawn. These days he mainly stays in his room and plays video games.  Erica is concerned that he is becoming depressed. She has to constantly remind him to take his medication (he was previously independent) feels like she is ‘nagging’ concerned about what is happening with his medication when he is at the farm.

Erica is hopeful that participating in the Healthcare Homes program will assist in better managing Liams’ care, particularly given his current physical and mental health status.

Question:

Nursing practice: Outline the relevant care coordination skills you as the Registered Nurses require to effectively manage Liam’s’ shared care plan.

ANSWER

Care Coordination Skills for Managing Liam’s Shared Care Plan

Introduction

The complex healthcare needs of a patient like Liam, who has Juvenile Idiopathic Arthritis (JIA) and Asthma, coupled with family dynamics and geographical challenges, demand strong care coordination skills from Registered Nurses (RNs). This essay outlines the essential care coordination skills required to effectively manage Liam’s shared care plan, addressing his medical conditions, family circumstances, and social and academic challenges.

1. Effective Communication

Communication is foundational in care coordination. RNs must engage in clear and timely communication with various stakeholders, including Liam, his family members, multiple healthcare providers (such as pediatric rheumatologists, pediatricians, physiotherapists, and GPs), and educators.

Effective communication includes active listening to Liam’s concerns, maintaining open lines of dialogue with family members, and ensuring that all healthcare providers are informed about Liam’s conditions, medications, and treatment plans. RNs need to facilitate regular case conferences or telehealth meetings to keep everyone involved on the same page.

2. Assessment and Evaluation

Care coordination begins with a comprehensive assessment of Liam’s physical, emotional, and social needs. RNs must regularly evaluate his health status, including pain levels, asthma control, and any emerging symptoms. Assessments should also consider the impact of his conditions on his academic performance and social interactions.

Evaluations should involve validated tools to assess his mental health, such as depression or anxiety scales, to address Erica’s concerns about his social withdrawal and depression. Regular review of Liam’s medication adherence and its impact on his conditions is crucial.

3. Collaboration and Teamwork

Care coordination often involves a multidisciplinary team of healthcare professionals. RNs must collaborate with physicians, therapists, educators, and specialists to create a cohesive care plan for Liam. This includes coordinating referrals, sharing assessment findings, and ensuring that interventions are consistent and aligned with Liam’s goals.

Collaboration also extends to liaising with non-healthcare professionals, such as school counselors or psychologists, to address Liam’s social and academic challenges resulting from his medical conditions and potential depression.

4. Resource Management and Navigation

Given the geographical challenges Liam faces, RNs must be adept at resource management and navigation. This involves helping Liam’s family access community resources, transportation services, and financial assistance programs to facilitate his medical appointments. RNs should be well-informed about available support services, both locally and in Sydney, to ease the burden of travel.

Additionally, RNs must assist Liam and his family in navigating the healthcare system, scheduling appointments, and managing paperwork related to medical referrals and insurance claims.

5. Cultural Competency and Sensitivity

Liam’s family dynamics, including his split custody arrangement, require RNs to be culturally sensitive and respectful of the diverse family structures and dynamics. Cultural competency is essential in ensuring that care plans are tailored to the unique needs and preferences of Liam and his family.

RNs should be attuned to any cultural beliefs or practices that may influence healthcare decisions and adapt care coordination strategies accordingly.

6. Advocacy and Education

RNs play a crucial role in advocating for Liam’s needs, both within the healthcare system and at school. This includes advocating for accommodations to support his academic challenges and addressing any instances of bullying or social isolation. Education is key, as RNs should provide Liam and his family with information on his conditions, medications, and self-management strategies.

Conclusion

Effective care coordination for a patient like Liam requires a range of skills, including communication, assessment, collaboration, resource management, cultural competency, advocacy, and education. Registered Nurses play a central role in managing shared care plans, particularly when dealing with complex medical conditions, family dynamics, and geographical challenges. By demonstrating these care coordination skills, RNs can help ensure that Liam receives comprehensive and holistic care that addresses his physical, emotional, and social needs, ultimately improving his overall well-being and quality of life.