I believe it is also paramount that a collaborative and interdisciplinary approach is employed. Things just tend to get a bit cumbersome when multiple entities start recreating the wheel rather than partnering with community based entities that specialize in providing the specific services that patients might need especially post-discharge. If the healthcare system could tap more into the village model of care, I think less folks would fall through the cracks.

Improving a care plan is everyone’s goal for patients success, the first step to this is to LISTEN. Many times were so busy making recommendations and we forget to listen. The patient/family can share what’s worked in the past, what they currently have, what they fear and so on. Crafting an improved care plan has so many layers, but is most beneficial to the outcome when all needed support is put into place for all the right reasons.

I would add to conduct a “strength- based” needs assessment to capitalize on the patient’s capabilities, coping skills to make appropriate referral that the patient would be willing to use. With that said, don’t forget you are cultural competency skills.

I am often asked by my clients to provide my professional opinion on care options outside of therapy. In these cases I usually give them a broad scope of options to explore and have them come back with a few choices that they feel would fit them. During their next session we would narrow those choices down based on what the client feels would help assist them with addressing their problem. I never chose for a client. This can present a liability problem if the client is not satisfied with my choice.

First, make sure that the physician in charge of the case has the experience and resources to coordinate a multi-talented team.

Have a knowledge of what services are out there to help a client. There are many agencies who are capable of handling many types of needs. For example: In home mental health agencies, YMCA organizations, Churches, Meals on Wheels, Home health agencies and etc

Having good relationships with community partners is essential to work effectively. You know who to contact at which agency in order to get the quickest most effective service.

have developed a vested interest in ensuring that each patient receives comprehensive, patient-centered care and a positive care experience. Not only is it the right thing to do, it is a core component of competitive strategy in today’s healthcare environment. I can also attest from my own journey as a patient how important the care experience is to overall well-being and recovery.

Communication is paramount when dealing with case loads. Sharing information and listening to the service provider as inter agency collaboration is the best way forward.

This may be one of the most difficult things to accomplish: matching resources that patients will follow with the coverage of their insurances. Advocating for insurances to reimburse for resources that will enhance their clients health should be top priority, since it can prevent unnecessary visits to an ED or admission.

Being on Medicare myself, and working in the Adult Medicaid Dept in my county's DSS office, it is wise to say I'm no expert; but I do understand how the medical insurance companies work. I have gained knowledge on how Medicaid works in regards to LTC, and other subject matters

Insurance is one of the most frustrating parts of the medical field. It is so important to advocate for your client so they get the necessary medication they need.

The case manager would coordinate medical services with the doctor’s office and the request for insurance coverage should go through the same.

Recentemente obtive sucesso junto a operadora de saúde, justamente por reunir argumentos necessários via relatório social, para autorização e sensibilização sobre a paciente idosa, evidenciando as fragilidades com relação a rede de apoio familiar da paciente, onde o adoecimento por si só já se configura algo que torna-se uma angustia familiar, ou seja, que essa dimensão de humanização é o que irá fazer a diferença no suporte e assistência prestada a paciente. Sendo autorizada a cobertura que de outra vez foi negada.

This, and also it’s important to initiate ongoing conversations with care partners regarding the care plan. Pro-active engagement in this regard closes service and care gaps.

In my private practice I make it a goal of mine to encourage my patients to take responsibility for their care. I often use the sentence “ I would like you to be in the drivers seat, I’ll be your co driver. We’ll get to the finish line together”. I believe this piece of encouragement is a huge resource. When you educate them about their condition and treatment choices, you empower them. I am known to demonstrate my care plan through models and diagrams, I also refer my patients to websites and videos that may be beneficial. We discuss goals and patient outcomes they are striving for, every session. Often patients feel powerless when I initially meet them. This is my way of reintroducing them to the power that lies within.

Critical to incorporate other providers to collaborate together. In doing so be honest when needs of patient extend beyond limitations of your current agency.

Resources for patient needs and care are important but mostly ensuring the patient has the buying to utilize those resources. Patients need to feel that the resources available are attainable for them and that it fits their needs as well as their lifestyle.

We must be an advocate for our seniors and disabled individuals. We must stay abreast of current and future services. Housing, is a main issue

I strongly encourage my clients to also advocate for themselves, to document their experiences/needs to assist in empowering them. I will also advocate for my clients because it is a collaborative approach.

Be sure to be just as valuable as a resource for others in your network! Always try to find a solution or potential solutions, follow up on any recommendations you make, and say thank you for any help that you received on behalf of your client.

This one is my favorite by far. As a RN being my patients advocate is not only a privilege but its my obligation to be either my patients sole voice or another voice to ensure my patients needs are being addressed safely, timely and with excellent care. It’s my duty to know my patients physical and emotional needs and to connect the proper resources and/or people in order for my patient to have a positive and favorable outcome.

Advocacy is central to my practice, and it takes many forms. It can be advocating to management to secure short term placement, advocating on behalf of a patient to their insurance company for an appeal, or advocating for them to healthcare providers who aren't understanding the patient's needs. I keep the patient involved in this process so that I can model this for them, as well as help them understand how to do it for themselves. I also empower my patients to use tools to help them advocate in the future, whether that's as simple as taking notes or writing down questions, or understanding the process of appeals with an insurance company.

Monitoring is key. We must stay in contact during and sometimes after services have ended. This will enable the client/family to understand that they are not alone in this process

Monitoring progress also reflects presence and ensuring sustainability to enhance progress in the client's healing process / journey

Operative word, Intentional. Purpose Perpetuates Progress... Thoughts, Actions, characterization converges in a confluence of optimized Self Actualization

Monitoring progress is essential in not just gauging engagement, but also lack thereof. Monitoring lack of progress allows a chance to reassess what is and isn’t working and seeing if there is a solution to overcome those barriers.