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.

3. 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.