What risks in care transition, vulnerable points of exchange


Assignment Task:

Henry's transcript is provided, however; please attempt to listen to the monologue for full effect.

After listening to Henry's story and viewing the video in the resources (What Matters Most), please offer an analysis of this case addressing the following questions.  Provide explanations and rationale for your responses. Consider care coordination/transitions that will enhance the best outcomes for Henry.  Don't forget to consider Ertha in this scenario. Consider all interdisciplinary and collaborative care that either would need. Follow the discussion guidelines

Omitting the peer replies.

Questions:

1. Discuss Henry's strengths. What risks in care transitions, or vulnerable points of exchange, (Mauk, 2023. p 951) can you identify?  Include rationale to support your answer.

2. Applying the 5 M's Model of What Matters Most (Video in the required resources-just the first couple of minutes will give you enough to find more information about the 5 m's without listening to the entire podcast), What are the 5 M's for Henry and Ertha? What do you feel matters most to each of them?

3. Which Evidence-Based Model Health Promotion Program would provide the highest impact for Henry and Ertha? Why?

4. Discuss various Community-based care management programs, such as PACE, GRACE, INTERACT, Ad-Life, etc. (Chapter 26)

5. Focusing on two of the programs that would have the most significant positive impact on Henry and Ertha. Include rationale to support your choices.

6. Discuss your role as the primary nurse in the interdisciplinary care of Henry and Ertha.

7. What are your two priority nursing diagnoses for Henry and Ertha? List at least 3 interventions for each diagnosis, supported with evidence, and a SMART goal (short term). Which interdisciplinary team members will be the most valuable for you to include to meet your goals for this patient? Include at least one interdisciplinary collaborative intervention (for medication education, a pharmacist, etc.).

8. Apply one of the previously discussed theories (Chapter 3) and offer your perspective of the case from this theoretical lens. Are there any concerns, or interdisciplinary collaborations, or interventions you would add or contribute more information?

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