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Posted: September 6th, 2023

Annie is a 69-year old Indigenous woman

Case Scenario
Introduction
Annie is a 69-year old Indigenous woman who normally lives near her daughter Sharelle (who has three children) in the Atherton Tablelands in north Queensland. Her three grandchildren in Queensland are Sarah (12 years old), Kelly (9 years old) and Alex (3 years old).
Annie is passionate about being an Aboriginal community member, enjoying the yarning sessions and attending local community events. She is currently visiting her son Tony and daughter-in-law Kate in Melbourne (within the Monash Health catchment area). Together they have a 9-months old baby called Lily. Kate is returning to work, so Annie has come to Melbourne for an extended stay to help care for Lily. Annie loves seeing Lily, getting to know her, singing to her and taking her for walks.
Annie has lived independently for several years. She was employed as a Koori primary school teacher, which she loved. Annie retired three years ago to support her daughter Sharelle to care for her three children.
Annie has Type 2 diabetes and hypertension, which were diagnosed when she was 60. She has managed her diabetes with the support of the local Aboriginal Health Service. Annie had been informed that her kidney function was deteriorating, which she had been following up at the local Aboriginal Health Service. Shortly after arriving in Melbourne, Annie became unwell and was admitted to hospital. Annie is now diagnosed with Chronic Kidney Disease (CKD).
Annie was not keen on going to hospital, because she has never been in a hospital before, is not familiar with hospitals, and has friends and family who have had bad hospital experiences. On discharge, Annie has agreed to be referred to the local Aboriginal Community-Controlled Health Organisation (ACCHO), which is close to her son’s home.
Lizzie is the Aboriginal Chronic Care nurse who is employed by ACCHO. At the hospital, Lizzie speaks with Annie to confirm the referral and arranges to visit her at home.
Background
Significant shifts have occurred over the last several decades in the policy and practice landscape of community and aged care services. As a consequence, the roles of the Registered Nurse and Registered Midwife have also changed in this practice context. An overview of Australia’s health system can be seen here.
This iSAP case reflects the changing health care needs of the Australian population and the growing need for PHC (Primary Health Care) in our health care system. The case is situated in the context of discharge planning and care transition from acute care to community care. Many different terms are used to describe this practice context including ‘discharge and transitional care’ and ‘transfer of care’.
The Victorian Government guidelines on Transfer of care from acute inpatient services, 2014 are aligned with the standards of The Australian Commission on Safety and Quality in Healthcare (ACSQH), The National Safety and Quality Health Service (NSQHS) Standards. Please familiarise yourself with these standards that inform quality and safety in the transfer of care.
As patient advocates and as vital members of the multidisciplinary and interprofessional care team, nurses and midwives play a critical role in facilitating the safe transfer of care across care settings and programs. Building on the themes of this unit (ageing and chronic and life limiting illness, PHC principles, clinical education, and EBP [Evidence based practice]) this assessment will help you to explore the important quality and safety considerations for practice in the transfer of care from acute inpatient services to community care.
Student Response
In preparing your Student Response (Part A of the case), please complete the following tasks.
1. Define ‘discharge planning’ and discuss the importance of discharge planning and care transition in relation to Annie’s needs. (approx. 100 words)
2. Briefly discuss two (2) known barriers to effective discharge planning in acute care services. (approx. 100 words)
3. Summarise in your own words and in dot point format 10 key steps for planning and implementing safe transfer of care as outlined in Transfer of care from acute inpatient services (2014). (approx. 250 words)
4. Construct a concept map that shows how you have drawn on Annie’s life story, health, environment, functional ability (physical abilities and limitations), and social wellbeing. The concept map should demonstrate person-centred care to the issues and improving her situation. Import (copy and paste) your concept map into your Student Response. (approx. 150 words)
5. Develop a care plan for Annie related to two (2) of her various health issues. Include the individuals and practitioners who will be involved. Use the table provided in the template (approx. 100 words).
6. Provide an EBP rationale for the following PHC principles (below) for Annie’s safe transition to community care. The rationale should include strategies from the National Aboriginal and Torres Strait Islander Health Plan (2021–2031) and the National Strategic Framework for Chronic Conditions (2017).

o cultural safety
o health literacy and self-management (for practical reasons these two principles have been combined)
o access to services
Presentation requirements:
• You are required to submit your answers in the templates provided for the Student Response (Part A) and the Student Report (Part B). The templates are provided as separate files in the AT3 assignment section. Do not change the structure of the template and do not delete the instructions in the template boxes.
• The instructions in the template boxes are not included in the assessment word count.
• The concept map must be legible with all information easy to read. It can be drawn or you can use the software provided under -Concept Mapping.-
• Use 11 font Arial.
• Use double line spacing.
• It is permissible to use dot point format in iSAP cases where asked.
• References are required for the Student Response (Part A) of this assessment.
• Submit in Microsoft Word format only; do not submit as a PDF or Pages document.
• You are required to use the APA 7 referencing in the unit.
• You must reference every statement of fact that is based on someone else’s work. In general, you should expect to use approximately one academic reference for every 100-150 words.
• Write within the suggested word count +/-10%. The word count includes in-text citations. The word count does not include the reference list or the instructions supplied within the the templates.

________________________________________

Part A

1. Define ‘discharge planning’ and discuss the importance of discharge planning and care transition in relation to Annie’s needs.

Discharge planning is the process of identifying and preparing for a patient’s anticipated health care needs after they leave the hospital. It is important for patients to have a smooth transition from hospital to home, as this can help to prevent complications and readmissions.

In Annie’s case, discharge planning is particularly important due to her age, cultural background, and health conditions. She is an older adult, which means she is more likely to experience complications after discharge. She is also an Aboriginal woman, which means she may have different cultural needs than other patients. Finally, she has chronic kidney disease, which is a serious condition that requires ongoing care.

A comprehensive discharge plan for Annie would include the following:

Assessment of her physical, social, and emotional needs
Development of a care plan that addresses her specific needs
Identification of resources in her community that can help her to manage her health
Education about her condition and how to manage it
Coordination of care with her primary care provider and other health care providers

2. Briefly discuss two (2) known barriers to effective discharge planning in acute care services.

Two known barriers to effective discharge planning in acute care services are:

Lack of time: Nurses and other health care providers are often under pressure to discharge patients as quickly as possible, which can lead to rushed discharge planning.
Lack of communication: There is often a lack of communication between the different health care providers involved in a patient’s care, which can make it difficult to develop a comprehensive discharge plan.

3. Summarise in your own words and in dot point format 10 key steps for planning and implementing safe transfer of care as outlined in Transfer of care from acute inpatient services (2014).

The 10 key steps for planning and implementing safe transfer of care as outlined in Transfer of care from acute inpatient services (2014) are:

Assess the patient’s needs.
Develop a care plan.
Identify resources in the community.
Educate the patient and their family.
Coordinate care with the patient’s primary care provider and other health care providers.
Communicate effectively with the patient and their family.
Monitor the patient’s progress.
Make adjustments to the care plan as needed.
Document the discharge process.
Evaluate the discharge process.

4. Construct a concept map that shows how you have drawn on Annie’s life story, health, environment, functional ability (physical abilities and limitations), and social wellbeing. The concept map should demonstrate person-centred care to the issues and improving her situation. Import (copy and paste) your concept map into your Student Response.
concept map Opens in a new window
Wikipedia
concept map

The concept map shows how Annie’s life story, health, environment, functional ability, and social wellbeing are all interconnected. Her life story has shaped her health beliefs and practices, and her health conditions have had a significant impact on her environment and social wellbeing. Person-centred care takes all of these factors into account when planning and delivering care.

5. Develop a care plan for Annie related to two (2) of her various health issues. Include the individuals and practitioners who will be involved. Use the table provided in the template.
care plan template Opens in a new window
Pinterest
care plan template

Health issue 1: Type 2 diabetes

Goal: Annie will manage her blood sugar levels within the target range.
Interventions:
Annie will self-monitor her blood sugar levels daily.
Annie will take her medications as prescribed.
Annie will eat a healthy diet.
Annie will exercise regularly.
Individuals involved:
Annie
Her doctor
Her nurse
A dietitian
A diabetes educator

Health issue 2: Hypertension

Goal: Annie will keep her blood pressure under control.
Interventions:
Annie will take her medications as prescribed.
Annie will make lifestyle changes, such as eating a healthy diet, exercising regularly, and quitting smoking.
Individuals involved:
Annie
Her doctor
Her nurse
A dietitian
A cardiac rehabilitation program

6. Provide an EBP rationale for the following PHC principles (below) for Annie’s safe transition to community care. The rationale should include strategies from the National Aboriginal and Torres Strait Islander Health Plan (2021–2031) and the National Strategic Framework for Chronic Conditions (2017).

Cultural safety: Cultural safety is the process of ensuring that all people feel safe and respected when receiving health care, regardless of their culture. This is important for Annie because she is an Aboriginal woman. Aboriginal people have a different cultural understanding of health and illness, and they may have different needs than other patients. Cultural safety can be achieved by providing culturally appropriate care, such as using an interpreter, providing culturally appropriate food, and respecting Aboriginal people’s spirituality.

Health literacy and self-management: Health literacy is the ability to understand and use health information. This is important for Annie because she has chronic health conditions that require ongoing management. Health literacy can be improved by providing clear and concise information about Annie’s conditions, teaching her how to manage her conditions, and providing her with support and resources.

Access to services: Access to services is the ability to get the health care that you need. This is important for Annie because she lives in a rural area. Access to services can be improved by providing transportation to appointments, making sure that there are enough health care providers in the area, and providing telehealth services.

The National Aboriginal and Torres Strait Islander Health Plan (2021–2031) and the National Strategic Framework for Chronic Conditions (2017) both emphasize the importance of these PHC principles. The National Aboriginal and Torres Strait Islander Health Plan (2021–2031) states that “cultural safety is essential for the delivery of high-quality health care to Aboriginal and Torres Strait Islander peoples.” The National Strategic Framework for Chronic Conditions (2017) states that “health literacy and self-management are essential for people with chronic conditions to manage their health effectively.”

References

Australian Government Department of Health. (2021). National Aboriginal and Torres Strait Islander Health Plan 2021–2031. Canberra, ACT: Australian Government.
National Aboriginal and Torres Strait Islander Health Council. (2017). National Strategic Framework for Chronic Conditions 2017–2022. Canberra, ACT: National Aboriginal and Torres Strait Islander Health Council.
Victorian Government Department of Health and Human Services. (2014). Transfer of care from acute inpatient services: A guide for clinicians. Melbourne, VIC: Victorian Government Department of Health and Human Services.

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