Coordination of Care and Case Management Essay

Coordination of Care and Case Management Essay

Coordination of Care and Case Management Essay

Personal Details

Name: AR

Age: 10

Gender: Male

Grade: 5th grade

Race: Hispanic

Religion: Catholic

Ethnicity: Mexican-American

Legal status: US citizen

Socioeconomic status, race, religion, ethnicity, legal status, gender, and sexuality can impact the child in various ways. People from low socioeconomic status cannot receive quality healthcare, so the burden of chronic diseases is heavier on them. Other factors such as gender, sexuality, ethnicity, race, and religion may attract discrimination when receiving healthcare depending on who is offering the services.

Framework for 21st-Century School Nursing Practice Principles 

Care Coordination

Care Coordination refers to the principle that brings together student-centered activities that are purposeful and deliberate in delivering health services across time. The school nurse oversees and aligns several evidence-based components and interventions, including identified practice components, that promote students’ health and well-being. Care coordination extends beyond chronic illness management and individual care (Gray et al., 2020). Implementing the practice components by school nurses addresses various social, mental, and health challenges children may be experiencing at the individual or student population levels.

Community/Public Health

This principle is a crucial part of the role of the school nurse. The school nurse applies community/public health knowledge, skills, and the stated practice components to provide proactive nursing services to schools across the community.

Leadership 

The leadership principle focuses on the leadership mindset rather than a position. Using the specified practice components, the school nurse leads the school’s culture and practice of health. The scope of practice here stems from advocacy for change to being a change agent showing the utmost professionalism.

Quality Improvement (QI)

Quality improvement entails collecting data and the pursuit of continuous improvement and growth. It entails school nurses participating in an ongoing process that produces the crucial evidence basis to guide school nursing.

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Standards of Practice

The school nurse’s thoughts, choices, and deeds are all guided by the standards of practice principle. Because of this, it is seen as encircling the other four principles but is not given higher prominence. The standards of practice, including the practice components, require a competent level of nursing care.

Role of School Nurse

The school nurse plays a crucial role in the family and advocating for the student’s health while in a multidisciplinary team. The school nurse acts as the primary healthcare provider for the children and liaison with the community. This role supports delivering healthcare services to the community and, at times, the staff.

Adrenal Insufficiency

Adrenal insufficiency refers to the deficiency of the hormones produced by the adrenal glands. Adrenal insufficiency can cause anything from mild nonspecific symptoms to life-threatening shock. There are three types of adrenal insufficiency: primary, secondary, and tertiary (Huecker & Dominique, 2020). A condition affecting the adrenal gland itself causes primary adrenal insufficiency. Secondary adrenal insufficiency is caused by a decrease in the amount of adrenocorticotrophin hormone (ACTH) released by the pituitary gland. In contrast, tertiary adrenal insufficiency is caused by decreased corticotrophin-releasing hormone (CRH) released by the hypothalamus.

Etiology

Primary adrenal insufficiency is defined by decreased aldosterone and cortisol production due to impaired gland function. The autoimmune destruction of the adrenal cortex is the most common cause of primary adrenal insufficiency (Huecker & Dominique, 2020). Other causes of primary adrenal insufficiency include adrenal hemorrhage, tumors, infections, and some drugs such as etomidate.

Signs and Symptoms

Adrenal insufficiency is frequently characterized by hypotension, altered mentation, fatigue, vomiting, weight loss, anorexia, and abdominal pains.

Health Concern 

The main health concern in adrenal insufficiency is the adrenal crisis. An infection may unmask ongoing adrenal damage leading to a sudden decrease and blood pressure and shock. This acute process is the adrenal crisis and may lead to a loss of life.

Medications Used

• Glucocorticoids like hydrocortisone: side effects include weight gain and mood changes.
• Mineralocorticoids like fludrocortisone: side effects include fluid retention and high blood pressure.

Influence of Cultural Characteristics on Management Plan

Diverse cultural characteristics influence the management plan to be developed by the nurse. AR is a religious Latino from a low socioeconomic background. These are some of the factors that are crucial to factor when developing an individualized care plan. The nurse should be culturally sensitive, factor in the family’s religious beliefs, and be able to explain to the family in a language that they understand well the plan of care to make an informed decision.

PLAAFP statement

This student’s learning and involvement in school are often hindered by fatigue and occasional absences due to medical visits or illness. When he is present, however, he participates fully in class activities and completes his work to the best of his ability.

IEP Goals 

1. Within the following academic year, AR will increase his attendance by reducing the frequency of medical-related absences by 20%.

Objective: During each quarter, AR will attend at least 90% of the school days.

1. AR will improve his self-advocacy abilities to articulate his requirements connected to his health condition successfully.

Objective: By the end of the first semester, AR will have identified and articulated his personal stress or fatigue triggers.

Developing an Individualized Healthcare Plan

An IHP will ensure that all pertinent information, needs, and plans are considered to maximize the student’s involvement and performance in school. In conjunction with the family, school, and healthcare practitioner, the school nurse will determine the type, amount, and degree of nursing care necessary for AR. The IHP also addresses other care areas, such as AR’s understanding of their illness, self-care abilities, and any alterations required to improve learning and avoid emergencies.

The first step is assessing the health needs, which may reveal the necessity for an Individualized Healthcare Plan. Assessment forms are used to aid in the development of the IHP. These forms can be handed to the parent to fill out or utilized by the school nurse during the parent interview. The data gathered will be utilized to complete the IHP.

Nursing Diagnosis

1. Fatigue is related to insufficient cortisol synthesis due to adrenal insufficiency, as evidenced by missed school days and inability to concentrate in class.
2. Risk for adrenal crisis related to an inability to cope with extreme stressors secondary to adrenal insufficiency.

Outcome Identification

1. By the end of the academic year, AR’s attendance will improve, and he will experience fewer absences due to fatigue and medical issues secondary to adherence to self-care.
2. AR will demonstrate increased knowledge and confidence in managing his condition by the end of the academic year.

Multidisciplinary Team

The care of this student will require a multidisciplinary approach composed of family, school administration, and a healthcare practitioner. The family will ensure that the patient gets patient-centered care and that their input is well appreciated in the care of the patient. The school administration ensures that the teachers know the signs and symptoms and any danger signs of the illness. A physician ensures that the nursing diagnosis by the school nurse is tailored to a medical diagnosis.

HIPAA and FERPA

HIPAA and FERPA are data protection laws. HIPAA protects medical records, but FERPA protects educational records. Educational health information should only be shared with those who have an educational interest in the information. In the case of AR, these laws ensure that medical information is well protected. Information cannot be shared without consent and only with the right people.

Emergency Action Plans

Name: AR

Age/Grade: 10, 5th grade

Classroom: Room 200

Emergency Contact: Guardian’s Call

Critical Signs and Symptoms 

• Fatigue
• Vomiting
• Low blood pressure
• Mood changes

How School Personnel Should Respond

1. The school nurse should be alerted.
2. AR should be put to rest.
3. Emergency communication should be done in case a severe medical condition ensues.
4. Any prescribed medication should be prescribed.

Evacuation Needs 

AR may require further support if an emergency evacuation is required to safeguard his safety and well-being. The emergency may be due to adrenal insufficiency. The school nurse, administrators, and teachers should know AR’s situation.

References

Gray, L., Klein, N., Meuret, C., Nelson, L., & Stahlnecker, L. (2020). Care coordination: A principle of 21st century school nursing practice with a focus on case management. NASN School Nurse, 35(4), 219–223. https://doi.org/10.1177/1942602×20928345

Huecker, M. R., & Dominique, E. (2020). Adrenal insufficiency. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441832/

National Association of School Nurses. (2020). Framework for 21st century school nursing practice^TM: Clarifications and updated definitions. NASN School Nurse, 35(4), 1942602X2092837. https://doi.org/10.1177/1942602×20928372

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Coordination & Case Management Assignment

Care Coordination & Case Management Assignment

Criteria Ratings Pts
This criterion is linked to a Learning OutcomePRINCIPLES OF CARE COORDINATION
Describes key principles of care coordination as defined by the Framework for 21st century practice for a student with a chronic health condition.

10 to >9.0 pts
EXCELLENT

Complete description of the key principles of care coordination as defined by the Framework for 21st century practice for a student with a chronic health condition.

9 to >7.0 pts
PROFICIENT

Description of the key principles of care coordination is nearly complete as defined by the Framework for 21st century practice for a student with a chronic health condition.

7 to >5.0 pts
SATISFACTORY

Description of key principles of care coordination as defined by the Framework for 21st century practice for a student with a chronic health condition is incomplete.

5 to >0 pts
NEEDS IMPROVEMENT

Poor description, lacking many key principles of care coordination as defined by the Framework for 21st century practice for a student with a chronic health condition.

10 pts

This criterion is linked to a Learning OutcomeSCHOOL NURSE AS ADVOCATE

Describes the role of the school nurse as advocate while collaborating with all partners on the multidisciplinary team.

10 to >9.0 pts

EXCELLENT

Completely and thoroughly describes the role of the school nurse as advocate while collaborating with all partners on the multidisciplinary team.

9 pts
PROFICIENT

Adequate description the role of the school nurse as advocate while collaborating with all partners on the multidisciplinary team. Lacks communication of the need for collaborating.

9 to >7.0 pts
SATISFACTORY

Less than thorough description the role of the school nurse as advocate while collaborating with all partners on the multidisciplinary team. Lacks communication of the need for collaborating.

7 to >0 pts
NEEDS IMPROVEMENT

Description the role of the school nurse as advocate while collaborating with all partners on the multidisciplinary team is sparse and difficult to comprehend. Lacks organization of material.

10 pts

This criterion is linked to a Learning OutcomeFICTIOUS CHILD DESCRIPTION
Fictitious child described by age, grade, and cultural characteristics defined in assignment

2 to >1.0 pts
EXCELLENT

Fictitious child clearly described by age, grade, and cultural characteristics defined in assignment

1 to >0.5 pts
SATISFACTORY

Fictitious child clearly described by age, grade, but an incomplete portrayal of cultural characteristics defined in assignment.

0.5 to >0 pts
NEEDS IMPROVEMENT

Factious child is poorly described. Details regarding age, grade, and cultural characteristics defined in assignment are missing.

2 pts

This criterion is linked to a Learning OutcomePATHOPHYSIOLOGY
Thorough description of pathophysiology, which includes: etiology, common signs & symptoms, medications, and/or treatments.

15 to >13.0 pts
EXCELLENT

Thorough description of pathophysiology, which includes: etiology, common signs & symptoms, medications, and/or treatments. Content is well organized and accurate.

13 to >11.0 pts
PROFICIENT

Complete Description of pathophysiology, which includes: etiology, common signs & symptoms, medications, and/or treatments. Content is well organized and accurate, but lacks organization of information.

11 to >7.0 pts
SATISFACTORY

Description of pathophysiology, which includes: etiology, common signs & symptoms, medications, and/or treatments, lacks one or more requirements of the assignment. Content is somewhat organized and 90% accurate.

7 to >0 pts
NEEDS IMPROVEMENT

Description of pathophysiology, which includes: etiology, common signs & symptoms, medications, and/or treatments, lacks multiple requirements of the assignment. Content is disorganized and thin, missing significant information about the criteria described in the assignment.

15 pts

This criterion is linked to a Learning OutcomeIHP/EAP DEVELOPMENT
Discussion of child’s cultural characteristics which may influence your IHP/EAP plan development.

5 pts
EXCELLENT

Thorough discussion of child’s cultural characteristics which may influence your IHP/EAP plan development. Includes all criteria listed in the assignment

5 to >4.0 pts
PROFICIENT

Thorough discussion of child’s cultural characteristics which may influence your IHP/EAP plan development. Includes most criteria listed in the assignment.

4 to >3.0 pts
SATISFACTORY

Thorough discussion of child’s cultural characteristics which may influence your IHP/EAP plan development. Includes some criteria listed in the assignment.

3 to >0 pts

NEEDS IMPROVEMENT

Thorough discussion of child’s cultural characteristics which may influence your IHP/EAP plan development. Missing many of the criteria listed in the assignment.

5 pts

This criterion is linked to a Learning OutcomePROCESS OF DEVELOPING IHP
Discussion of the process of developing the IHP for this student using the nursing process.

10 to >9.0 pts
EXCELLENT

Demonstrate excellent knowledge of the nursing process of developing the IHP for this student. Content is complete and well organized and includes a complete discussion of the process.

9 to >7.0 pts
PROFICIENT

Demonstrates knowledge of the nursing process of developing the IHP for this student. Content is mostly complete and organized though it does not include a complete discussion of the process.

7 to >5.0 pts
SATISFACTORY

Demonstrates some knowledge of the nursing process of developing the IHP for this student, but content is thin, incomplete and/or lacking organized and/or complete discussion of the process.

5 to >0 pts
NEEDS IMPROVEMENT

Does not adequately discuss the nursing process in developing the IHP for this student, content is very thin, incomplete and/or lacking organized and/or complete discussion of the process.

10 pts

This criterion is linked to a Learning OutcomeNURSING DIAGNOSIS

Two nursing diagnoses clearly stated in complete format with 2 outcomes expected from the interventions

4 pts
EXCELLENT

Two nursing diagnoses clearly stated in complete format with 2 outcomes expected from the interventions appropriately created for the student.

3 pts
PROFICIENT

Two nursing diagnoses stated but complete format with 2 outcomes expected from the interventions are not clearly written or appropriately created for the student.

2 pts
SATISFACTORY

One of Two nursing diagnoses clearly stated in complete format, with 2 outcomes expected from the interventions appropriately created for the student.

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1 pts
NEEDS IMPROVEMENT

Two nursing diagnoses are not clearly stated in complete format and the 2 outcomes expected from the interventions are not appropriately created for the student.

4 pts

This criterion is linked to a Learning OutcomeMULTIDISCIPLINARY TEAM
Describes the multidisciplinary team, who is on the team and why.

2 pts
EXCELLENT

Completely describes the multidisciplinary team and who is on the team and why (what is the significant contribution to the team).

1 pts
SATISFACTORY

The multidisciplinary team does not represent the needs of the student. Explanation of why members were chosen is not complete or clearly described,

0.5 pts
NEEDS IMPROVEMENT

Key members of the multidisciplinary team are not included in the list. Some explanation of members may be present, but is insufficiently describing the need for their role.

2 pts

This criterion is linked to a Learning OutcomeHIPAA & FERPA

HIPAA & FERPA implications for the school nurse coordinating care and case management. Includes description of how these apply to sharing information about this student.

5 pts

EXCELLENT

Provides complete and thorough description of both HIPAA & FERPA implications for the school nurse coordinating care and case management. Includes description of how these apply to sharing information about this student.

4 pts
SATISFACTORY

Provides complete and thorough description of both HIPAA & FERPA implications for the school nurse coordinating care and case management. Includes description of how these apply to sharing information about this student, Adequately describes the differences but is unclear about some significant limits posed by HIPAA & FERPA.

3 pts
PROFICIENT

Provides somewhat complete description of both HIPAA & FERPA implications for the school nurse coordinating care and case management. Includes a incomplete description of how these apply to sharing information about this student.

2 pts
NEEDS IMPROVEMENT

Provides some description of both HIPAA & FERPA but provides limited discussion of the implications for the school nurse coordinating care and case management.

5 pts

This criterion is linked to a Learning OutcomeEAP
EAP provides critical signs & symptoms school personnel must be alert for and exactly how they should respond.

4 pts
EXCELLENT

EAP clearly describes all critical signs & symptoms school personnel must be alert for and exactly how they should respond. Description is written in “non-healthcare provider” language and Follows format in Selekman et al. (2019) pp 184-185 and includes all details as described in Module 5 Assignment description.

3 pts
PROFICIENT

EAP clearly describes most critical signs & symptoms school personnel must be alert for and exactly how they should respond. Description is mostly written “non-healthcare provider” language and Follows format in Selekman et al. (2019) pp 184-185 and includes all details as described in Module 5 Assignment description.

2 pts
SATISFACTORY

EAP clearly describes several critical signs & symptoms, school personnel must be alert for but does not tell them exactly how they should respond. Description is sometimes written in “non-healthcare provider” language and Follows format in Selekman et al. (2019) pp 184-185 and includes all details as described in Module 5 Assignment description.

1 pts

NEEDS IMPROVEMENT

EAP clearly does not describes critical signs & symptoms school personnel must be alert for and exactly how they should respond. Description is written in healthcare provider language therefore not following suggested format in Selekman et al. (2019) pp 184-185 and includes all details as described in Module 5 Assignment description.

4 pts

This criterion is linked to a Learning OutcomeGrammar, Proper Citation, EAP slide, Permission to use slide

Grammar, proper citation, and use of APA 7th edition. EAP added as Final slide of presentation. Permission to use slide added to grant/not grant permission of use by peers and placed as next slide in presentation. Labeled Properly.

3 pts

EXCELLENT

Less than 2 grammar, citation issues. EAP is added as the last page of the presentation. .title page. Labeled properly.

2 pts

SATISFACTORY

More than 2 grammar, and more than 2 citation issues. EAP added as Final page of presentation. Labeled Properly.

1 pts
NEEDS IMPROVEMENT

Many grammar, and 2 citation issues. EAP added as Final page of presentation.