Introduction
The current paper is centered on developing a care plan for the home safety of elderly bedridden patients who have experienced a heart attack or stroke. The well-being and speed of recovery of such patients, particularly those with concomitant diseases, depend on the observance of hygiene rules and the doctor’s prescriptions. It affects well-being and mood, as well as psychosocial comfort. Therefore, it is essential that relatives or field specialists can take care of such patients.
SMART Goal
It is planned to implement care management software to help provide home-based training for nurses and enhance patient education options. Elderly patients and their families can be considered social learners who gain care information from nurses. The changes are planned to be implemented within one year, and progress will be measured monthly after the training programs and new software are implemented. The measurements will be achieved through the analysis of the patients’ responses and their general health outcomes.
Plan
The plan encompasses several steps and spheres that require attention. A hospital is preparing to discharge home-based care for bedbound patients after a heart stroke. The current plan allocates the scholarly healthcare-related strategy, which is called the Situation, Background, Assessment, Recommendation (SBAR) approach.
The SBAR communication strategy is centered on identifying the underlying problems of the situation and providing a solution based on culturally competent approaches (Achmad & Raymond, 2019). This approach is suitable due to the need to work with the patients in home conditions, which requires a unique communication pattern to ensure their physical and psychological comfort.
Care Management Software
The first goal is to implement or develop the care management software, which is designed to remotely monitor the patient’s state and coordinate necessary changes in the treatment plan with clinicians. Sharing electronic medical records on the patient’s state will allow one to monitor them more closely. According to recent research, home-based medical care (HBMC) is often insufficient for patients, especially in rural areas (Cornwell et al., 2018).
It is associated with the need for more organized control over nurse practitioner (NP) visits and support. Measuring the outcomes of the objectives can be achieved through the software’s data collection mechanisms. The primary aim is to deliver medical care to bedbound patients at home without exception. The various software can help coordinate the work of NPs.
Training of Nurses
One of the significant problems in providing home-based care is the presence of cultural biases and the need for nurses’ training in developing cultural competencies. Thus, the second objective is to design continuous training for the development of cultural competency in NPs. The health outcomes of older adults often depend on their emotional state (Heponiemi, Hietapakka, & Kaihlanen, 2019). One of the primary aims of care is to ensure the fulfillment of patients’ sociological needs.
In other words, any potential biases in the work of NPs should be avoided. The SBAR approach will be rational to allocate during training. It can help NPs to adapt to any situation and provide bias-free care and psychological support for patients (Kempen et al., 2022). Such training programs should be annual, providing new approaches to cultural competencies and innovating care options to ensure the complex increase of care quality. The objective efficiency can be measured by monitoring the experiences of NPs and patients through interviews and questionnaires.
Family and Patient Education
The last goal to be mentioned is educating the patients and their families. Building efficient communication with the family of the patients to ensure their education related to the necessary procedures to support the physical and mental state of the patient. Nurses should provide such services in the scope of communicating with the families of elderly patients. Despite providing nursing care at home, the patient’s psychological state directly depends on their communication with a family member and whether they receive a decent level of communication and support (Imhof et al., 2019).
Researchers believe that educating patients and their families is an essential component of home-based care, particularly for the elderly, who can quickly adapt to care when interacting with family members (Imhof et al., 2019). It would be rational to ensure that the particular brochures serve as a notification for family members, guiding them through the home care process.
Many issues, such as cross-cultural communication, may occur in this instance. The development of cultural competencies of nurse practitioners should be addressed during the training programs. For the family members of bedbound patients, it is essential to understand how to ensure a high level of social interaction with bedbound people. The progress on this goal is estimated based on the patient’s health outcomes and gained experience.
Community Resources
- California’s Caregiver Resource Center and Family Caregiver Alliance provide opportunities for interaction with caregivers, considering the individual needs of the patients.
- A stroke support group provides information for maintaining health and delivering the treatment plan for people who have experienced strokes.
- Meals-on-Wheels provides valuable information on creating and following individual diet plans (Family Caregiver Alliance, n.d.).
- The Assistive Technology Fund provides financial and preferential opportunities for assistive technologies that support transportation for patients with disabilities.
- The home caregiving grant allows patients to get nursing or caregiving support.
Conclusion
The preliminary care coordination plan includes three objectives based on allocating the SBAR communication strategy. Each objective helps monitor and organize the HBMC for bedbound elderly patients who had a heart attack or stroke. The objectives involve close observation of the patients’ psychosocial and physical states. One of the most vital aspects of the plan is the training of NPs to develop cultural competencies.
The coordination care plan is realistic and achievable. Each of the mentioned goals is patient-oriented because it is centered on improving general health outcomes and the patients’ physical and psychosocial state. The plan primarily focuses on communicating the patient’s needs and treatment plan to increase the quality of care.
References
Achmad, F., & Roymond, S. (2019). The influence of training handover based SBAR communication for improving patient’s safety. Indian Journal of Public Health Research & Development, 10(9), 1280–1285.
Cornwel, T., Leff, B., Ritchie, C., & Yao, N. (2018). Use of home-based medical care and disparities. Journal of the American Geriatrics Society, 66(9), 1716–1720.
Family Caregiver Alliance. (n.d.). Caregiving at home: A guide to community resources. Caregiving.
Heponiemi, T., Hietapakka, L, & Kaihlanen, A. (2019). Increasing cultural awareness: qualitative study of nurses’ perceptions about cultural competence training. BMC Nursing, 38.
Imhof, M., Ris, I., & Schnepp, W. (2018). An integrative review on family caregivers’ involvement in care of home-dwelling elderly. Health & Social Care in the Community, 27(3), 95–111.
Kempen, G., Metzelthin, S., Passosm V., Rooijackers, T., Rossum, E., & Zijlstra, R. (2022). Effectiveness of a reablement training program on self-efficacy and outcome expectations regarding client activation in homecare staff: A cluster randomized controlled trial. Geriatric Nursing, 43, 104–112.