The work has not been graded but I like the output that was submitted to me. Is it possible for the same prof to do the next assignment I will be submitting? If possible, I will greatly appreciate it.
Patient-centered care focuses on the patient’s healthcare needs for a healthier outcome. It is
not all about their health, but instead, it is about them being emotionally, spiritually,
mentally, socially and financially fit. It is evident in many ways such as in the doctor’s office
where patients are given centered care. It also happens in hospitals where the patient decides
who they will see or who they don’t want to visit. Finally, there is personalized medicine as
well as therapies. It goes beyond the regular assessing, diagnosing, and treating of the patient.
As it takes time, having a ‘what else’ approach will make the whole process more patient-
centered than just the patient giving superficial information. Suppose in Agnes’s case, she has
the evident signs of an injury from a fall, but knowing what else is bothering her or in this
case, having her give the practitioner her history is essential (Aﬁlalo, et. al., 2009). From
here, prioritizing the given agendas will not take as much time and will give importance on
what to deal with first.
In this case, we have Agnes who is a 67-year old woman who sustained injuries from
a fall at home. The pain made her immobile and injuries included swelling and bruising of
her right leg, a skin tear on her right arm, fractures as well as broken ribs. With the above
information, living well for Agnes will mean having to consider quite some amount of
factors, given her medical and social history (Hubbard, 2010). It is vital for the caregiver to
provide honest information that will make the patients make well-informed decisions.
Older people have complex care and health needs. Themes as frailty can be an issue.
In the case of Agnes, she is 67 years of age, and she lives alone evident by the fact that her
neighbor called the ambulance, the following day. For this case, I would consider frailty as
the central aspect. It is regarded as a state of vulnerability due to poor homeostasis
inflexibility and is usually so after a stressful event causing cumulative degeneration in most
of the physiological systems within a patient’s lifetime. There is a need to come up with more
efficient ways of detecting it, as well as in measuring its seriousness during the clinical
procedural practices. It would be of great help in offering insights as to appropriately select
the elderly for invasive procedures or instead drug treatments. It would also make the basis of
the shift more goal-oriented (Hubbard, 2010).
Person-centered care, in this case, means that Agnes will feel wanted and she will not
face the pressure that comes with the complex disease or nurses being too busy for her.
Instead, patient-centered care means that the counselors and staff members will care for her at
all times. Agnes will have to sit down and explain what is wrong, as she was the only one in
the house when she fell and she knows herself best. For the staff to make a difference, they
need to understand that they are the change and they can make a patient change their thinking
pattern. By smiling or even warmly welcoming Agnes to the hospital and explain the results
from her tests will be a good start (Chaves, Semba & Leng, 2009). As an old woman living
by herself, it is expected that she is lonely and she might want company and warmth in her
injured and immobile state.
For successful chronic disease intervention, it is going to need a coordinated
multidisciplinary care team and the central core of the patient’s self-management. A decline
in some functioning will impede the patient’s ability to successfully self-manage the disease
unless treatment and support approaches are provided and adapted accordingly. For a patient
to self-manage will vary depending on areas affected, the severity of the impairments and
complexity of self-care tasks required by the patient. A health provider should however not
be making decisions for the patient concerning treatment and care until they understand their
values and goals e. Patient value, patient priority, and patient goals should be accounted for in
such a call, and the clinician takes the role of ‘convincing’ the patient.
For the best patient-centered care, multidisciplinary attention takes into consideration
each disease or injury into account. Such transformational care will lead to faster answers and
even better results. Instead of blindly diving into the patient’s case, a practitioner will be able
to know from which angle to look at the situation. In as much as a patient is referred to
another doctor for assessment and maybe treatment, it is better for the patient to at times go
for such an option in one hospital as it saves on time in critical emergencies and can give the
clinicians a clear understanding of what happened and what they are dealing with. If Agnes
had some part of her treatment done in hospital A, it becomes hard for hospital B to try out
different or even potentially better treatment. Had she been newly diagnosed at hospital B,
then the process becomes easy and faster for hospital B.
How I would care for Agnes is by first realizing that I can be patient-centered in tiny
ways. It could be with the food or the noises, to wanting a family member around. I would
then create an environment that caters to her privacy and to offer better personalized care. By
having a humanistic approach, I will not only help in demystifying the system, but I will also
be playing a part in healing by merely relating to her needs as a human. For Agnes, her needs
are in all aspects – mental, physical, physiological and psychological.
In the case of Agnes, this condition has brought consequences due to the age-related
weakness in most of her physiological system and which will result to her health status
suddenly changing due to the stressor event which was the fall. Complexities will become
evident in all facets of her life as financial, physiological, psychological, social and even
A multidisciplinary team involved will act in response to changes in the condition of
the disease. Will the situation be managed by medication or will it be through surgery? By
finding and utilizing appropriate resources from people to process to equipment to medicine.
As with old age comes multiple conditions, there is no reason that she cannot live a healthy
and even independent life. Their health and social needs also ought to be taken care of. It os
better when this team works with other health care providers, and maybe even getting insight
from family and friends, to make informed choices about the patient’s treatment, with the
final step being to take action.
It may be hard for her to maintain independence in her home that is why the
multidisciplinary programs needs to identify, assess and treat geriatric conditions as
depression, dementia, falling and incontinence. Such patient-centered care means that
Agnes’s qualities of life will not be affected and the team working together keeps her
independent and safe in her environment offering help when needed.
Prudent self-management requires the clinician to take responsibility in assessing the
patient’s current capabilities, identify the barriers to successful self-management and make
efforts to implement management strategies designed and customized for the patient. For
multidisciplinary care, the patient is at the center of everything done. In the case of Agnes,
she will see her medical practitioners from different departments, as oncologists (given her
cancer history), physiotherapists, surgeons or doctor, will not be separated. She will have to
work with her a dietician, those in pathology or laboratory medicine, practice providers,
pharmacists, social workers, and nurses. Pooling experts acts to give the patient an all expert-
surrounded aspect in terms of the care they need. It will enable them to all talk to the patient
together, discuss the issue at hand, and come up with treatment plans together. In as much as
a patient is involved and feels the comfort of knowing what is or will happen, it saves the
patient time and energy of having to make four appointments.
Research has proved that if patients feel like the team of doctors is supportive,
then they become more receptive (Cunningham & Campion, 2015). They get an optimal
treatment plan and a timely start to their treatment, allowing for the better care of the patient.
For this reason, Agnes is likely to positively respond to their concern and treatment knowing
that this ‘team-approach’ she is getting will lead to her peace of mind and appropriate care.
Multidisciplinary care as an approach to Agnes’s case will make me better understand
her needs. Her mobility has been hindered from her swollen and bruised leg, she might have a
hard time breathing, and the skin tear may make doing ordinary things hard. Because of this,
Agnes will need someone who will care for her every need. In the case of seeing her doctors,
she might need to make as little trips to the doctor as possible and having such an approach
and bringing together various specialists makes work easier for Agnes. Together, they will
discuss preventive, and care methods for her and she, on the other hand, can give important,
relevant information regarding her medical history (Streit, 2006).
Self-management skills are to be taught on a regular. Eating healthy and the
importance of exercise are some of the primary ways a patient can look after and control their
health and condition. There are different strategies used when it comes to self-management.
By doing group medical visits to about ten patients, they will all feel heard. This saves time
while still focusing on individual needs despite the group members needing undivided
attention. Another strategy is in actually sitting through with a patient to analyze results or
showing and explaining to them the results. It makes a difference when the topic of the
conversation is the problem affecting the patient, and what the treatment would be. It also
provides security that they are well taken care of (Abadir, 2011). Also, the ‘what else’
approach will help in a patient defining what is bothering them without a clinician having to
interrupt. Though it may seem a bit oversensitive, it shows a patient how much care the
professionals can give. It is also based on research that more positive behavior change over
time came from patients who said they trusted their physicians.
Care coordination is a point of care application used by all members of the
care team including nurses and social workers. The most effective care management program
has been seen to be those where the care team members interact directly with the patients. It
is recommended that web applications be used that will give the list of patients and those who
messaged the doctor, their pending activities as well as a list of appointments (Florini &
Magri, 2002). In as much as it is about providing excellent care, it also about keeping them
well. In providing the education, care and support mean empowering them to be active
partners in their health management, while meeting their goals and needs using their
Intensive coordination care services work with people who have complex issues. Such
an approach works well with families that have severe issues and could benefit from this
approach. With proactive components like clear communication, coming together of experts
and pooling resources will help in improving patient’s wellness. Explaining to patient’s the
reason and value for their health as well as making them reconsider their priorities, by
mindful awareness they can respond in ways that improve their health. A patient also gets to
find out what works best for them during their recovery or pursuit for better living.
Abadir, M.(2011). “The frail renin–angiotensin system”. 27(1), 53–65
Aﬁlalo, J., Karunananthan, S., Eisenberg, J., & Alexander P. (2009). Role of frailty in
patients with cardiovascular disease. 103(14), 1620 – 1630
Chaves, H., Semba R. & Leng, X. (2009) Impact of anemia and cardiovascular disease on
frailty status of community-dwelling older women: the Women’s Health and Aging Studies I
and II.60(8), 720 – 740
Lipsitz, L. (2012 0. Dynamics of stability: the physiologic basis of functional health and
frailty. 57(3), 115–25.
Nuo X., Ding, Q., & Chen, D. (2010).Microglia in the aging brain: relevance to neuro-
degeneration. 5(3), 12-16.
Streit, J. (2006). Microglial senescence: does the brain’s immune system have an expiration
date? 29(6), 506 – 510.
Cunningham C. & Campion, S. (2015). Central and systemic endotoxin challenges
exacerbate the local inﬂammatory response and increase neuronal death during chronic
neuro-degeneration: Journal of Neuroscience. 25(5), 2275 – 2284.
Florini, J. & Magri, A. (2002). Hormones, growth factors, and myogenic diﬀerentiation.
59(7), 1710 – 1715
Lamberts, W. (2007). The endocrinology of aging. 278(3), 419 – 424.
Hubbard, E. (2010). Inﬂammation and frailty measures in older people. 13(4), 3103 – 3109.
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