Interdisciplinary teams are regularly used to take care after surgery for older adults because of their complex healthcare needs. It is necessary to work in a team which concerns with the judgment and management of older adults with complex illness as in case of Mr. Trosack who is recovering from right total hip replacement surgery.
Interdisciplinary teams play important role to give care to patients (Farrel, Schmitt and Heinemann, 2001).These teams work together as an identified unit or system.
These issues are important when planning for management of elderly discharged patients because old people need very much care. Their ability to adapt to the environmental conditions, patient centered care and staff with special expertise in the care of older adults all should be taken into account as suggested by Counsell et al (2000).
Medical issues: Interdisciplinary team needs work on medical issues of Mr.Trosack as he had no physical examination in 10 years. He is not aware of what vitamins he has been taking for 10 years. He also requires dietary counseling because he is suffering from diabetes and obesity. Psychological/emotional issues: Psychological treatment is also required because Mr.Trosack is depressed by people started calling him “Disabled” after his surgery. He is also suffering from loneliness because his wife died 2 years back.
Living conditions: Living condition of Mr.Trosack is not good because he is living in third floor which is not good for the patient who is recovering from hip replacement surgery.
2. Members that will make up the team that will determine the discharge will be:
3) Social worker
A. 1. The Physician and a surgeon: Physician and surgeon plays the important role in treating Mr.Trosack by performing hip surgery and by performing routine checkups, prescribe medicines. He must ensure of medical issues given the right weight in the decision-making process.
2. Nurse: Nurse plays the important role in this process by evaluating psychological, physiological. Nurse performs all over physical checkups on the older adult by applying various techniques of observation, review, palpation, diagnostic technique, and rhythm section. Nurse need to use relevant testing instruments and analyze the data gathered in collaboration with the health care team in order to find out the health status of Mr.Trosack.. Nurse will need to modify and coordinate the services requires in order meeting the patient’s need of health care. This process acts as a promoter for the older adult to improve his health status.
3. Social worker: The role of the social worker on an interdisciplinary team is as follows:
1. Diagnosis/Assessment. – Social worker goal is to analyze family strengths and weaknesses and help the family to create a plan that can help the patient. They explain the goal of treatment to family members in help achieve patient’s good health.
2. Care Management. This includes problem identification.
3. Cooperation. If the patient’s family lives out of the area social worker can also serve as a connection between them. Social worker can help keep family members in touch and follow up them as needed.
6. Advocacy. Social workers’ training, includes confidentiality
3. Issues from the safety assessment are as follows:
This can be conducted with the help of patient and family’s permission; case manager can conduct a safety assessment of the patient’s apartment. In the case of Mr.Trosack, his apartment is very small and is messy with furniture which could be difficult for Mr.Trosack to move with the walker. His bathroom is small which is very dangerous for him. The most important safety issue is that he is living on second floor that can be harmful for Mr. Trosack. Case manager should consider all these safety issues and consult to his family members to shift him in the apartment of ground floor because there is no elevator in this building.
B.1. Care manager needs to talk to the family member of Mr.Trosack by concerning about follows issues that are as follows:
Family need to support Mr.Trosack by giving emotional support to him because he is suffering from depression.
Family need to arrange a cook so that Mr.Trosack can have homemade food because doctor advised him not to take junk food. He is having food in his bakery which is not good for health.
Care manager should ask his family member to live with him as he needs their help in walking, and taking medicine on time.
Care manager should discuss about the safety issues because he is living in the second floor which is not good for the hip replacement surgery patient.
b. Social isolation leads to depression in older adult’s recovery from surgery as discussed in Mr. Trosack case. I believe that Mr. Trosack recovery is affecting because he is depressed due to social isolation. He needs the care of his severe care situation with the help of a physiotherapist, a pharmacist, and the home care coordinator. Isolation leads to higher use of medical services and increased risk of again admission in the hospital.
c. Psychological factors play important in recovery process: Larger fear or pain prior to surgery is related with a very slow and more complex surgical recovery. In this process, anxiety plays the important role in hindrance in healing during both behavioral and physiological mechanisms, but these pathways have been unclear. Recent work in the field of psychoneuroimmunology (PNI) has stated that stress retards healing of the wound. Pain also has adverse effect on endocrine and immune function. A bio behavioral model is used which is based on these and other data; it suggests a number of routes through which psychological and behavioral responses can influence surgery and postsurgical outcomes. Strong evidence supports the effectiveness of interdisciplinary team care in a variety of settings, including acute care as suggested by Douglass, (2001), sub acute care as suggested by Andrew et al (2001) and home care as suggested by Beltz et al (2000)
2. Recommendation of discharge placement for Mr.Trosack is as follows:
Due to lack of family support and his state of living condition a care taker should be there in order to take care of him
There is a need of social worker, who can resolve the differences between the patient and his family member.
Due to lack of safety measures, he must not be discharged in this time because he lives alone on second floor which is very dangerous for him to go back to home.
Need physiotherapist for helping him in the treatment.
After collecting all the above information of the patient case a recommendation of discharge placement will to be made.
Documents of Mr.Trosack:
Surgery: Right total hip replacement (THR)
Weight: 210 lbs.
Glucose: non insulin dependent diabetes
hearing loss at 60% in his left ear