Navigating Complex Health Challenges

Complex care management is associated with determining the complex health needs of a patient and then develop and implement an effective and high standard care plan to meet all these needs thereby promoting the holistic wellbeing of the patient (Kuluski et al. 2017). This essay will present a complex care management plan of a patient. First, the background and the pre-medical history of the patient will be disused. Then the essay will demonstrate the innovative strategies in meeting the holistic needs of the patient thereby supporting self-care and promoting the health and wellbeing of the patient. This essay will also discuss the implementation of the health service provision into the care plan developed for effective care management of the patient. This essay will also present the assessment as well as management of the personalised care plan for the patients. Under NHS (2015), the personal identity of the patient is kept confidential throughout this essay.

Mr Smith is a 40-year-old with Dyslexia, a learning difficulty (LD) that affects his ability to read; his medical history included Deep Vein Thrombosis (DVT) in bilateral legs, Hypertension and Type 2 Diabetes Mellitus (T2DM). He was referred to the DN service for diabetic management/ medication review. The referral suggests he has elevated HBA1C levels of 80, where the GP suspects a patient is not taking his medication. Anticoagulation clinic changed Warfarin to Apixaban due to non-concordance with regular blood tests for warfarin therapy and patient safety. He increased hospital admissions for Hyperglycaemia. There is a lack of attendance to GP despite calls to arrange appointments to review medications and annual diabetic review. Medication includes Metformin, Gliclazide, Lantus, Amlodipine, and Apixaban (Raveendran et al. 2018).


From the holistic assessment, it is seen that the complex health condition of Mr Smith poses an adverse impact on his physical, psychological and emotional wellbeing, due to ageing, he suffers from difficulties in remembering the medicines that he needs to take regularly (Reinhard, 2019). Even most of the time he cannot remember that where he keeps his medicined box. He also has no knowledge on which medicines he is proscribed by the doctors for managing his sugar level which is one of the common reasons for his uncontrolled sugar level (De Veer et al. 2018). Many times, he takes the wrong medicine instead of the right one. He is unable to have a healthy eating and proper nutritious diet as he often forgets where he places the vegetable and the non-veg items. Most of the time he cannot remember whether he takes his meal at night or morning. Therefore, he often skips meals as he thinks that he has already eaten the meals. He has a limited understanding of his complex health condition and can not understand what types of therapy and treatment he receives from the caregivers. He only knows that he has a high body sugar level for which he must skip foods that are enriched with high sugar (Means, 2020). But in many times, he forgets that which foods he needs to eliminate from his regular diet. Therefore, most of the time he eats potatoes, sweets and pumpkins that enhance his blood sugar level. Most of the time he is over or under medication as he cannot remember whether he has taken the medicines or not. He is unable to remember the date and time thereby he is unable to track his appointments to doctors, the time to take the medicine and check-ups (Adu et al. 2019). This is why he suffers from hypertension, hyperglycaemia and polyuria, due to uncontrolled glucose levels. Due to DVT, Mr Smith needs proper assistance for personal care and proper self-management. He also needs a well-organised and relevant complex care plan for effective management of type 2 diabetes.

The holistic health assessment also shows that Mr Smith has high safety risks such as the risk of recurrent falls while wandering on the lawn or while taking personal care. Due to overdose or underdose of medications, there is a high risk of falls due to hallucination and sudden unconsciousness. As mentioned, by Kuluski et al. (2017) the hyperglycaemic condition of Mr Smith is also associated with frequent urination which can interfere with the safety of Mr Smith while he goes to the bathroom frequently for urination. According to Reinhard (2019), there are many cases of head injuries ad hip fraction by falling on the bathroom floor for the hyperglycaemic patients due to poor hygiene and cleanliness of the bathroom. On the other hand, high sugar level also causes severe headache which makes people get faint thereby increasing their risk to accidents. In this context, Mr Smith has it risk of falls or sudden injuries due to accidents which can cause severe health risks as well as life risks (De Veer et al. 2018). On the other hand, there is deteriorating DVT symptoms in Mr Smith which will impact on his mobility, thereby interfering with his health and wellbeing.

Innovative strategies can be developed to meeting the holistic needs of Mr Smith that are identified in the above-mentioned paragraph. A good and well-organized safety framework is crucial for Mr Smith to protect his from recurrent falls or any kind of injuries and accidents. Under this safety framework, Mr Smith carer would be appointed for assisting Mr Smith to protect his from falls while performing any activity such as wandering, dressing, bathing, cooking and gardening (Brenner et al. 2018). Another important key worker for proving safe ca to Mr Smith is community care nurses who will assist Mr Smith in conducting self-care without facing accidents or injuries (Yasmin et al. 2020). The community care nurse and the carers will work collaboratively with Mr Smith to provide his proper assistance in managing all his basic activities with maintaining proper safety and protection. The carers will be there all time for Mr Smith while he is going to perform the self-care activities such as dressing or going to the bathroom or eating (Pamungkas et al. 2020). Under NMC (2015), all nursing professionals must work under their level of competence and professional practice to ensure the safety of patients. The community care nurse will make a regular observation of the physical health of Mr Smith, communicate to his about his feeling regarding his own physical ad mental health, enquire regarding his medication, provides his with the right dose of medicine timely, discuss with the concerned doctors there is a normal change in the health of Mr Smith and provide his with the best possible emotional and mental support (Lohan et al. 2017). Mr Smith could be referred to the local memory clinic for proper counselling and psychotherapies which will improve his memory. In addition to this, Mr Smith would also be referred to undertake the Cognitive-behavioural theory (CBT) which is highly effective in improving the cognitive skill in Mr Smith thereby will improve his decision making and problem-solving skill (Lee and Lee, 2018). In memory clinics, the care providers need some modern memory aids such as the Doro Photo Button Phone which has visual contacts and phones numbers. Doro Photo Button Phone is a widely used memory aid for assisting ageing patients to remember the phones and names of family members and relatives (Bosun-Arije et al. 2020). On the other hand, the home monitoring devices and the electronic appliance monitor are also useful memory aids in the case of Mr Smith, in terms of tracking his activities and movements. Reminder messages can also be used for Mr Smith to remember the times of medicine to be taken. In this context, the voice message can be designed to play at the predesignated time.

An effective monitoring system of blood sugar levels will be conducted regularly in the case of Mr Smith. For a continuous blood glucose monitoring process. A sensor can be implanted beneath the skin of Mr Smith which will sense the blood sugar level up to three months regularly (Basit et al. 2018). As mentioned by Lohan et al. (2017), while providing care for effective diabetes management, the community care nurse must provide the proper health education and training to the patient about how the patients can check his or his blood sugar at home. In this context, Mr Smith can recommend an aqua blood glucose monitor devices which will assist his to check his blood sugar level at any time when he feels it is necessary. According to Bosun-Arije et al. (2020), self-monitoring of blood glucose is necessary for involving patients in the effective prevention and management of diabetes. hise for self-testing, Mr Smith only needs to use a small drop of his blood at the tip of the blood glucose meter and the current blood sugar level will be automatically shown on the screen.

The community care nurse who is appointed for taking care of Mr Smith must have good knowledge on safe and effective medication administration to ensure that all the prescribed medicines are administered in a safe way to this patient (Basit et al. 2018). Under NMC (2015), each registered nurse must have a clear understanding of safe medication administration to ensure that the right dose of medicine is administered into the patient’s body by following all the guidelines under the healthcare provision (NMC, 2019). As Mr Smith is unable to take care of his medication regimen, the community care nurse will make a regular check on whether Mr Smith is provided with the right dose of medicine at right time as per the prescription (Gordon, 2019). Additionally, the community care nurse will also check that whether there is any case of overdose or underdose of medicine to Mr Smith, and if it happened then the community care nurse must make an immediate MET call to the concerned doctors, pharmacist and senior nurse.

For conducting effective coordination care, the DN must have good listening skills, communication skills, interactive skills, decision-making skills teamwork skills, effective leadership skills, and resilience skills. As stated by Stanisstreet et al. (2018), for effective coordination of care, nurses must have good skills in maintaining transparent communication with the patient to determine the holistic health needs of the patient. In the case of Mr Smith, the DN must conduct clear and effective verbal communication and listen to the complex health needs, pain issues, choice for treatment and preference of Mr Smith. The DN must work in collaboration with the patient (Mr Smith), his career, community care nurse, the pharmacist, the doctors and family members of Mr Smith. According to Winocour et al. (2018), for providing high-quality complex care, nursing professional must ensure that they must work in partnership with the patients and other healthcare providers to provides the best possible healthcare support to the patient. in the case of Mr Smith DN must work as a team with local statutory and voluntary healthcare agencies, doctors and the carer to ensure that Mr Smith will receive a safe and high standard of care under which he will be assisted in managing self-care, having a healthy diet, self-monitoring of his blood sugar and the physical parameters and doing proper exercise regularly (Wu et al. 2018). The DN would have a good leadership skill through which the DN can lead the subordinates nursing staff to cope with all the health care policies and provision for managing diabase and providing high-quality care to Mr Smith.

Under NICE (2019), recommends the effective management of diabetes is not only associated with implementing effective clinical intervention but also is strongly associated with the non-clinical intervention. The clinical intervention of diabetes management includes medicines, insulin therapy, blood glucose monitoring (Basit et al. 2018). Whereas the non-clinical management of diabetes includes providing health education, proper health information regarding how to manage the symptoms of diabetes. In the case of Mr Smith, the community care nurse must educate Mr Smith regarding improving his knowledge on what is diabetes, the cause of diabetes and how he can manage and prevent the symptom of diabetes.

The National Health Service (2021), recommends the effective management of diabetes through conducting a health promotion campaign, educating people regarding monitoring their blood glucose and train them to follow a healthy eating and proper medical regimen to prevent diabetes (Vas et al. 2017). Under the Long-Term Plan (LTP) of NHS (2021) for diabetes management, Mr Smith would be provided with proper assistance regarding improving his lifestyle, eating habits, the skill of managing his self-care, responding to the cultural changes and diversity, respecting patient autonomy and preferences (Adu et al. 2019).

Self-management skill is important in patients in managing their complex health condition (Wu et al. 2018). The DN must play crucial roles in educating Ms Smith to develop a strong self-management skill in him. In this context, the DN will provide proper healthcare information to Ms Smith regarding how he can manage his health by following a healthy and systematic lifestyle (Stanisstreet et al. 2018). In this context, DN will work in partnership with dietician and nutritionist to recommend Ms Smith a healthy diet chart and healthy food intake which will reduce the sugar level of Ms Smith thereby improving his physical health condition through developing self-management skill in Ms Smith, DN can improve his decision making ability, problem solving skill and good reasoning skill which will enable Ms Smith to take the right decision regarding solving any problem in his professional and personal life (Vas et al. 2017). Through effective and strong self-management skill, Ms Smith can improve his self-confidence and self-esteem thereby assisting Ms Smith to improve his overall psychological and menta health. Under Diabetes, GOV.UK (2015), Mr Smith must be provided with proper assistance in how to develop effective lifestyles changes to manage the blood sugar level within the normal range (Basit et al. 2018). The care providers must assist Mr Smith to follow a prescribed medical regimen such as taking the medication regularly, do not skip meals, eat healthy food which is enriched with proteins and necessary nutrients but low in carbs (Gordon, 2019). Under Diabetes, GOV.UK (2015), Mr Smith will also be supported to develop self-management skills by providing his with proper training for how to check his blood glucose at home and take medicined time to time (Wu et al. 2018).

To conclude, the role of a nurse is critical in health promotion and self-management. In the management of Diabetes, there are structured pathways in place to improving the care of people with diabetes and a learning disability. Healthcare professionals play a vital role in ensuring that every patient has the right level of knowledge concerning their diagnosis and prescribed medication. If an HCP cannot gauge or find it harder to educate and communicate with LD patients, they should identify this need for training. Patients should always be allowed to try alternative options if it prevents deterioration of their condition because one treatment will not necessarily be suited for all despite cost implications.

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Health care professionals should always ensure reasonable adjustments are made for patients with LD. Multidisciplinary teams should work together to manage complex needs to manage their condition within the community best.

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