Federally Qualified Health Center

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Dora Smith has come to the Federally Qualified Health Center (FQHC) for several problems she is experiencing. Your group performed an interprofessional team evaluation with the results in the case below. Your team is now meeting to create a plan for Dora.

Dora Smith is a 52-year-old woman (DOB 6/1/68), that has been a patient at the Federally Qualified Health Center (FQHC) for the last 8 years. She attends her appointments sporadically. The last time she was seen was 1.5 years ago. Note: The FQHC has behavioral health, physical health, dental, and pharmacy services all in one building

PMH:
Chronic low back pain
Opioid use disorder
Gastroesophageal reflux disease
Depression
High blood pressure
Peripheral neuropathy bilateral feet
Type 2 diabetes mellitus
Medications
Oxycodone 5 mg every 3 hours PRN
Rantidine 150 mg every 12 hours
Metoprolol 50 mg every 12 hours
Hydrochlorothiazide 25 mg daily
Gabapentin 600 mg every 8 hours
Clonidine 0.3 mg every 8 hours
Social history: Patient is divorced. She lives in a second-floor apartment with her medium sized dog
Reason for visit: Recent fall 1 month ago when walking her dog (tripped on the dog leash). She sustained a concussion and reports increased low back pain since the fall. Today, she reports severe pain in a tooth on bottom left side of her mouth that started about a week ago.
Examination
Vital Signs
Temp: 99°F
HR: 90 bpm
BP: 159/85 mmHg
RR: 12 bpm
Height 5’2”, Weight 170 lbs
Labs (from ED visit 1 month ago)
Laboratory Test

Result

Normal Range

Sodium

130

135-145 mEq/L

Potassium

5.5

3.5-5.0 mEq/L

Chloride

100

98-107 mEq/L

CO2

20

22-26 mEq/L

Glucose

150

90-108 mg/dL

BUN

20

5-25 mg/dL

Creatine

1.7

0.6-1.1 mg/dL

WBC

9,000

4,5000-11,000/mm3 %

Hgb

10

13-18 g/dL

Hct

32

36-49%

Platelets

150,000

145,000-450,000/mm3

Dora was assessed in the dental clinic, prescribed antibiotics for an abscess and is to return in 12 days for a follow-up appointment. The next available appointment is one month from the dental clinin assessment visit.
Questions

What are the issues?
What is your desired outcome?
What stakeholders will you need to work with to achieve your desired outcome?
Describe in order, what major steps will need to happen to achieve your desired outcome?
What unique strengths can each discipline bring to the team?
How could your team include patients’ preferences into the plan?
What strategies could you use if you encountered resistance from a colleague while working on a plan to achieve your desired outcome?

 

Sample Solution

Interprofessional Care Plan for Dora Smith

Issues:

  • Chronic health conditions:Dora has several chronic conditions including low back pain, opioid use disorder, GERD, depression, high blood pressure, neuropathy, and type 2 diabetes.
  • Medication management:Potential medication interactions and need to assess if current medications are addressing her chronic conditions effectively.
  • Uncontrolled pain:Increased low back pain and recent dental issue contribute to uncontrolled pain, potentially impacting her overall health and well-being.
  • Sporadic healthcare utilization:Infrequent visits limit opportunities for comprehensive care and medication management.
  • Social factors:Living alone with a pet might present challenges with managing daily tasks and healthcare needs.

Desired Outcome:

  • Improved pain management through a multidisciplinary approach, potentially reducing reliance on opioids.
  • Improved medication adherence and management of chronic conditions.
  • Increased healthcare utilization to ensure preventive care and timely interventions.
  • Improved overall health and quality of life for Dora.

Stakeholders:

  • Dora Smith (Patient)
  • Primary Care Physician
  • Behavioral Health Specialist
  • Pharmacist
  • Dentist
  • Care Coordinator (if available)

Action Plan:

  1. Initial Assessment:
    • Primary Care Physician (PCP) conducts a comprehensive physical exam and medication review.
    • Behavioral Health Specialist assesses Dora’s mental health and potential impact on pain management and medication adherence.
    • Pharmacist reviews medication regimen for interactions and potential adjustments.
  2. Development of a Care Plan:
    • The interprofessional team collaboratively develops a plan addressing:
      • Pain management strategies (e.g., physical therapy, pain medication tapering plan, behavioral interventions for coping with pain).
      • Medication adjustments and adherence support.
      • Management of chronic conditions like diabetes and high blood pressure.
      • Mental health support for depression.
      • Referral for social services or in-home support if needed.
  1. Implementation and Follow-up:
    • The PCP coordinates care and schedules regular follow-up appointments.
    • Each team member delivers their specific interventions and monitors progress.
    • The care plan is adjusted based on Dora’s progress and feedback.

Strengths of Each Discipline:

  • Primary Care Physician:Provides comprehensive care, manages medications, and coordinates referrals.
  • Behavioral Health Specialist:Addresses mental health concerns impacting pain management and medication adherence.
  • Pharmacist:Ensures medication safety, effectiveness, and adherence.
  • Dentist:Provides dental care and addresses oral health concerns.
  • Care Coordinator (if available):Acts as a central point of contact, helps navigate the healthcare system, and schedules appointments.

Including Patient Preferences:

  • Involve Dora in all discussions about her care plan.
  • Explore her preferred methods for pain management and medication management.
  • Address any concerns she might have and tailor the plan to her individual needs and goals.

Overcoming Resistance from Colleagues:

  • Openly discuss any disagreements with colleagues in a respectful and professional manner.
  • Present evidence-based recommendations to support your suggestions.
  • Focus on achieving the best possible outcome for Dora through collaborative care.
  • If a consensus cannot be reached, escalate the issue to a supervisor or team leader for further discussion.

Additional Considerations:

  • Explore the availability of transportation assistance for Dora to attend appointments.
  • Educate Dora on the importance of medication adherence and healthy lifestyle choices to manage her chronic conditions.
  • Connect Dora with community resources that might provide support services or social interaction opportunities.

By working together as a team and incorporating Dora’s preferences, this interprofessional care plan can help her achieve improved pain management, better control of her chronic conditions, and a healthier overall quality of life.

 

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