Problem
Developing a Coordinated Care Management Plan
Jimmy Jansen is a 44-year-old man with type 1 diabetes mellitus. He will be discharged from your hospital and referred to a home health agency for coordinated care management follow-up at home. He is experiencing multiple complications from his diabetes, including the recent onset of blindness and peripheral neuropathy. His left leg was amputated below the knee last year because of a gangrenous infection of his foot. He is unable to wear his prosthesis at present because he has a small ulcer at the stump site. His chart states that he has been only "intermittently compliant" with blood glucose testing or insulin administration in the past despite the visit of a community health nurse on a weekly basis over the past year. His renal function has become progressively worse over the past 6 months, and it is anticipated that he will need to begin hemodialysis soon.
His social history reveals that he recently separated from his wife and has no contact with an adult son who lives in another state. He has not worked for more than 10 years and has no insurance other than Medicaid. The home he lives in is small, and he says that he has not been able to maintain it with his wife gone. No formal safety assessment of his home has been conducted. He also acknowledges that he is not eating right because he now must do his own cooking. He cannot drive and states, "I don't know how I'm going to get to the clinic to have my blood cleaned by the kidney machine."
Task
Mr. Jansen has many problems that would likely benefit from coordinated care management intervention. Use the attached template to establish a coordination of care plan. (As you type in the template it will expand as needed) Use in-text citations to support your thoughts
A. Make a list of five nursing diagnoses for Mr. Jansen that you would use to prioritize your interventions. Be sure to prioritize actual problems prior to "risk for" problems in your nursing diagnoses chosen.
B. Then make a list of at least five goals that you would like to accomplish in planning Mr. Jansen's care. Make sure that these goals reflect realistic patient outcomes.
C. What referrals would you make? What interventions would you implement yourself? Would you involve other disciplines in his plan of care?
D. What is your plan for follow-up and evaluation?