Follow-Up Care Plan and Conclusion (Sections IV and V)

Overview: In your final milestone in preparation for your final project submission, you will work on a draft of the follow-up care plan and conclusion to your
collaborative care guide. As with previous milestones, you will be working on these elements as they relate to Jean’s case study:
Jean is an 87-year-old woman who was admitted to Manchester Community Hospital, in Manchester, New Hampshire, after having a debilitating stroke
that paralyzed the left half of her body. She is a widow, and her three adult children live in different states. She needs assistance eating, transferring to
her wheelchair, and most other activities of daily living. Her medical issues related to the stroke are quickly being resolved, and it is time to begin
assessing her needs for discharge and post-discharge. It is important to note that Jean’s savings have been totally depleted and her medical bills are
mounting since her healthcare insurance has proven to be inadequate to cover her medical expenses. Her limited pension and social security barely
covered her living expenses prior to her stroke and are unlikely to cover the escalating expenses that she will undoubtedly encounter based on her
medical condition. Moreover, Jean has been clinically diagnosed with PTSD after being raped by a neighbor in her home two years ago. She is still
grappling with the effects of the trauma, even as the criminal case against the perpetrator slowly moves forward. Although her family modified the
home to make it more secure and less vulnerable to intrusion, her current lack of mobility is weighing heavily on her psychologically. Despite her current
issues, Jean derives great comfort from her faith as a devout Catholic. She typically has a wonderful sense of humor and is highly organized, having
worked as an elementary school teacher during her earlier years. She participates regularly in the local garden club and on her neighborhood welcoming
committee. She has a wide circle of friends with whom she interacts. Her children are currently staying in Manchester to oversee her care and to
contribute to the development of her post-discharge care plan. It is unclear whether any of the children will stay on after her discharge to help care for
Jean, but this seems unlikely unless considered essential by the medical team. An interdisciplinary team is being developed to design a comprehensive
plan for Jean’s post-discharge care.
The follow-up care plan occurs after discharge from the hospital. The initial discharge plan addresses immediate needs of the client as he or she transitions back
to his or her home. Once that transition is complete, some issues remain. These are the issues that will be addressed in the follow-up care plan. Consider
agencies in the community that can assist the patient in addressing the issues. As you work on your plan, you may find the following resources valuable:
 Improving Hospital Discharge Planning for Elderly Patients
 Best Practices Manual for Discharge Planning
Prompt: Create a draft of Sections IV and V of your final project, a collaborative care guide.
IV. Follow-Up Care Plan
Create a comprehensive follow-up care plan for Jean, applying her needs identified in the case study.
A. Applying best practices, explain the basic post-discharge client needs represented within the case study.
B. Develop strategies to arrange provision of services to the client.
C. Develop effective strategies to address the client’s post-discharge financial needs. What strategies will you use to ensure client access to
recommended services?
Consider organizing this section of your milestone in table format:
Client Needs (Including Financial Needs) from the Case Study
Issue 1:
Issue 2:
Issue 4:
Issue 5:
Strategies to Address Needs and Suggested Agencies
That Will Provide Needed Services (Including Financial Needs)
Issue Strategy and Agency/Source of Services
V. Conclusion
Discuss the impact of navigating available resources for both inpatient and discharge needs on the client in the short and long terms. Finally, describe
the expected outcomes of the care plan. Be sure to include the following:
A. Based on the case study, how would the difficulty of navigating the available resources for both inpatient and discharge needs impact the client
physically and psychologically?
B. What long-term effects will the strategies you developed for addressing the client’s inpatient and post-discharge financial deficits potentially
have on her survival and well-being?
C. Describe the expected outcomes of this care plan. Given the follow-up care plan and the anticipated impact of available resources, what realistic
outcomes for the patient do you foresee? Consider physical, emotional, and financial outcomes.
Guidelines for Submission: Your draft of Sections IV and V should be about 2 to 3 pages in length and should use double spacing, 12-point Times New Roman
font, one-inch margins, and APA formatting.
Critical Elements Proficient (100%) Needs Improvement (75%) Not Evident (0%) Value
Follow-Up Care Plan:
Client Needs
Accurately explains the basic post-discharge
client needs represented within the case
study; all needs are cited and explained
clearly and succinctly, including evidence of
the need
Explains the basic post-discharge client
needs represented within the case study, but
explanation is not accurate or lacks detail
and evidence
Does not cite all of the basic post-discharge
client needs and/or fails to explain each
Follow-Up Care Plan:
Provision of Services
Develops comprehensive, effective strategies
to arrange provision of services to the client;
strategies minimize complexity, are realistic,
and are directed to the specific client needs
Develops strategies to arrange provision of
services to the client, but strategies are not
comprehensive; one or more strategies are
overly complex, unrealistic, and/or not
directed at specific client needs
Does not develop strategies to arrange
provision of services, or most strategies are
ineffective and/or unrealistic
Follow-Up Care Plan:
Financial Needs
Develops effective strategies to address
post-discharge financial needs and ensure
client has access to services; there is a
consistent match between strategies and the
financing to ensure service delivery
Develops strategies to address the client’s
post-discharge financial needs, but not all
strategies are matched with financial
resources to ensure that the client has access
to those services
Does not develop strategies to address the
client’s post-discharge financial needs, or
most strategies are not matched with
sufficient financial resources to ensure
service delivery
Conclusion: Available
Describes how the difficulty of navigating the
available resources for both inpatient and
discharge needs would impact the patient,
based on the case study; includes potential
impact on client physical and psychological
well-being, and the possibility of resorting to
less desirable alternatives (where client
needs are only partially met)
Describes how the difficulty of navigating the
available resources would impact the patient
in general terms, but does not include both
physical and psychological well-being, fails to
relate description to the case study, and/or
neglects to describe both inpatient and
discharge needs
Does not describe how navigating the
available resources would impact the
patient, or the description is vague and
Conclusion: LongTerm Effects
Thoroughly describes the potential long-term
physical and psychological effects, both
positive if they are successful and negative if
they fall short, of the developed strategies
for addressing the client’s inpatient and postdischarge financial deficits; all relevant
factors are considered
Describes the potential long-term effects of
the developed strategies for addressing the
client’s inpatient and post-discharge financial
deficits, but description lacks sufficient
detail, overlooks relevant factors, or fails to
consider physical and psychological effects
Does not describe the potential long-term
effects, or fails to address critical factors
Conclusion: Expected
Comprehensively and realistically describes
the expected outcomes, physical and
psychological, of the care plan if successfully
implemented; supports expectations with
citations from the case study
Describes the expected outcomes of the care
plan, but description is not comprehensive or
partially fails to logically follow from the
Does not describe the expected outcomes, or
expectations are not realistic given the
Articulation of
Submission has no major errors related to
citations, grammar, spelling, syntax, or
Submission has major errors related to
citations, grammar, spelling, syntax, or
organization that negatively impact
readability and articulation of main ideas
Submission has critical errors related to
citations, grammar, spelling, syntax, or
organization that prevent understanding of
Total 100%

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