Assignment of a Complete Case Management Program
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Assignment of a Complete Case Management Program
The following case study is an example of a comprehensive case management program. Case management programs and the served populations are diverse; this is only one example of case management implementation.
Bill Wilson is a 76-year-old white male. He recently relocated to the Reno area from Wisconsin to be closer to family. Bill was recently admitted to the hospital for treatment of chest pain, hypertension, and poor glucose control. The case manager contacts Judy, a nurse practitioner at the diabetic clinic, and asks her if she will accept Bill as a primary care client in the TCM program. Judy accepts Bill into the TCM program and makes an appointment tomorrow, the day after Bill’s hospital discharge.
Past Medical History
Metabolic syndrome: obesity (310 pounds, 5’11” BMI 43.2)
Type 2 diabetes, poorly controlled, A1c 9.5 during hospitalization
Hypertension
Coronary artery disease with two stents placed 5 years ago after a myocardial infarction
Peripheral vascular disease, both lower legs; healing wound on right foot
Diabetic neuropathy, both feet
Decreased vision due to diabetic retinopathy
Assessment
Bill has a 10-year history of type 2 diabetes, poorly controlled, with an A1c of 9.5. He has been taking metformin 1000 mg oral twice a day. His blood glucose is often 200 to 250.
He admits to forgetting his medication more than two times a week. He does not perform fingerstick glucose monitoring because of the cost of supplies and low vision problems.
Individual
Bill is a retired employee of Johnson and Johnson in Racine, Wisconsin. His monthly income with Social Security and other retirement is $1700 per month.
Since Bill moved to Reno, he is residing in a one-bedroom apartment. His rent is $700 a month and includes utilities. He has a car and drives. He recently enrolled in a Medicare managed care program that includes medications.
Family
Bill was married for 45 years. He is now a widower. He is not currently in a relationship. He has two siblings, a brother and a sister. Both siblings live near their children in the Midwest. Bill moved to Reno to be close to his daughter, Sally, who is his only child.
Sally resides in a single-family home with her husband, Harry, and their three teenage children. Sally is an electrical engineer, employed full time, and her husband is a university English professor.
Community
Because Bill is new to the community, he is not familiar with community services that are available. Judy will put him in contact with senior services that are available and will make referrals as appropriate.
Diagnosis
Judy saw Bill in the clinic. She took his history, performed a physical examination, and reviewed his discharge medications. With Bill, she developed a care plan with specific goals for Bill’s health promotion and disease stabilization.
The diagnosis list included:
Type 2 diabetes, poorly controlled
Metabolic syndrome: obesity (increased body fat around the waist), hypertension, high blood glucose, elevated cholesterol level
Hypertension
Hyperlipidemia
Coronary artery disease
Peripheral vascular Disease
Diabetic neuropathy
Visual disturbance, retinopathy, and cataracts
Individual
Judy and Bill mutually agreed that he lacks knowledge on how to manage his diabetes. Bill often eats foods high in carbohydrates and fats. It is convenient for Bill to eat fast foods.
Bill admits that he often forgets to take his medications. He also acknowledged that he does not understand his medications and which medication treats his chronic conditions. Bill has not seen an ophthalmologist in more than 5 years.
Bill has a limited income, but he thinks that he can live on his monthly income, especially now that he is on a Medicare managed care program that covers his medications.
Bill does not exercise and finds exercise boring.
Family
Bill’s daughter, Sally, is concerned about him. She is busy with her job, but is available to assist him on the weekends. She is willing to assist him with meal preparation and invites him to her house for meals at least once a week.
Community
Bill is new to the community. He does not know what services are available for seniors in the area. Part of his care plan includes an introduction to community services and activities.
Planning
Individual
Bill is at risk for hospital readmission. He requires education to learn how to manage his chronic illnesses. Most importantly, Judy suggests that Bill begin the Diabetic Education course offered at the clinic.
The program includes information on how to monitor and control his blood glucose. The program also includes healthy cooking classes to encourage the attendees to prepare healthy meals at home.
Judy is also setting an appointment for Bill to meet with the program’s pharmacist to learn about his medications.
Short-Term Goals
Bill and Judy agreed on short-term goals that include the following:
Diabetic education classes that include healthy cooking. A meeting with the program’s dietitian to identify specific goals for Bill’s meal plan.
A referral to a podiatrist who comes to the diabetic clinic three times a week to see patients, with the goal of the foot wound healing completely. Education on foot care, wearing socks, appropriate shoes, and foot inspection.
A referral to an ophthalmologist for a complete eye examination.
A referral to a local gym. Bill’s Medicare managed care health program pays for the monthly membership.
An appointment with an exercise physiologist at the gym to evaluate Bill’s current physical condition and create an exercise plan for Bill.
Because Bill finds exercise boring, the physiologist will work with Bill to develop an exercise program that will interest Bill to encourage continuation of the program.
Long-Term Goal
Bill’s long-term goals include the following:
Control of his type 2 diabetes, including an A1c less than 7.5
Weight loss
Continuation of the exercise program
Continued follow-up with his primary care provider, Judy
Family
Short-Term Goal
Bill’s daughter, Sally, wants to make sure that Bill has the diabetic testing supplies that he needs. She contacts the Medicare managed care program and requests that the testing supplies be provided. The company representative assures Sally that the supplies are covered.
They will provide Bill with a glucometer and testing supplies. They will provide the products as soon as possible so Bill can learn how to do blood glucose monitoring while enrolled in the Diabetic Education program.
Long-Term Goal
The long-term goals that Bill’s family want him to achieve include:
Diabetes control
Weight loss through diet and exercise
Independent living in his own apartment
Social interaction Community
Short-Term Goal
Judy will provide Bill with his referral information. Judy will also provide Bill with resources available in the community that he can explore.
Long-Term Goal
Socialization in the community. Bill plans to start attending the church that his daughter and her family attend. He wants to explore the activities offered at the local senior center.
Attendance at exercise, completion of the Diabetic Education program.
Intervention
Individual
Judy’s primary focus for Bill is to stabilize and improve his chronic illnesses. Making referrals to podiatry, ophthalmology, diabetic education, and exercise physiologist.
Family
Bill has good support from his daughter and her family, who are involved in his life.
Community
Bill has a stable living environment. He is able to drive and explore the community resources that Judy has provided.
Evaluation
Individual
Judy and Bill work together as a team to evaluate his chronic disease management. As necessary, they make revisions in his care plan.
Family
Bill’s family remains involved in his life. They are a strong source of social support for him.
Community
Judy will evaluate Bill’s progress in becoming involved in community activities and services.
RUBRIC
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