Question

Frank Taylor, RN, is the discharge planning coordinator on the geriatric diabetic services team. He is also chair of the service's Practice Council. Because of the changes stimulated by healthcare reform, the unit leadership has begun working on developing a continuum of care geriatric diabetic services model to ensure adequate services are available to these patients across their continuum of need. Focusing on this population's continuing healthcare needs requires Frank and his colleagues to reflect on which model of service might integrate the disciplines and link a variety of geriatric services in a model that would support geriatric diabetic patient care needs along the health continuum. The task appears complex and challenging, but Frank and his colleagues sense that it is the right priority to address.

Question 1: Because this task will require interdisciplinary team deliberation and decision making, who should be at the table? Why? Describe which services will be provided for this population. How do those persons reflect the continuum of care for this patient population?

Question 2: What is the specific role of the nurse both in development of this continuum of care model and in its coordination, facilitation, and integration once the team has designed and formulated their desired approach for this population?

Answer 1

Question 1:
Interdisciplinary team members are patient ,physician,nurse practitioner,educator, RN, social worker,therapist and health aides..They are the important team can initiate the process of decision-making,interprofessional shared knowledge and theory based approach for implementation..Teamwork and interprofessional collaboration need for patient health outcomes..This collaboration provide new knowledge towards patient-centered care..shared decision making skills help succeed in health care outcomes..This interdisciplinary team collaboration in effective disease management focus on prevention,self-empowerment on patient,psychotherapy support and apply evidence based practice..The team work with collaboration deliver the exceptional diabetic care..
Question 2:
continuum of care model focus on patient -centered health practices it focus on health education before discharge and access to community based management program to continue the care at home..Health care agencies as a non profit health system serve in diabetic program it prevent hospitalization and provide quality care for geriatric and growing population..Depends on patient needs the nurse visit the patient help in assessment,education and medication management and risk reduction..the social workers involve in psychosocial,financial needs and lifestyle modification and make sure healthy behavior..therapist in geriatric care for rehabilitation,adaptive devices and exercise for their activity and self care.. challenges in self care responsible for geriatric population need different environment and management strategies..it can be applicable with long term care facilities..They focus on attention on the heterogeneity of health status of the geriatric population..older individual have more high risk with treatment related complication..multidisciplinary approach and intervention provide education about hypo and hyperglycemia symptoms,dietary therapy,foot care,shared decision making approach helps to achieve the goals with no harm for elderly diabetic population..