Worksheet #4: Complex Case Analysis Part IWhen we last encountered BT, he had worked with the CC RN to set health goals
based on BTs values and preferences. BT joined Noom® Healthy Weight Program to
establish long-term healthy habits and change his relationship with food.
Setting the stage for the visit with BT and his wife: Cross-Cutting Communication
and pre-visit preparation: The CC RN, PCP, dietitian/nutritionist, oncologist, and
behavioral health professional met to discuss BTs case, recent diagnostics, and care
plan. At that meeting, the team identified options for BTs pancreatic cancer treatment.
The CC RN shared BTs health goals related to weight loss and blood pressure,
preventative care gaps they are working on closing. The PCP and oncologist presented
the HC team with surgical treatment options for BTs Stage 1 resectable tumor located at
the head of the pancreas, the nutritionist helped identify dietary and nutrition needs for
pre- and post-Whipple procedure. The behavioral health professional requested a covisit with BT and his wife to assess baseline coping measures pre/post-surgery
supports.
The CC RN schedules a co-visit with BT and his wife and his health care team.
At the visit, BT reports a 4-pound weight loss. BT says feels like Noom is exactly what
he needs and that he got his wife to use the App as well. She has lost 2 pounds so far.
BT and his wife have started brisk walking 4 times a week and the results are starting to
show. In addition, BT has noticed his latest blood pressure reading was a few points
lower than previous readings at his PCPs office.
After meeting with the CC RN, the HC team walks BT and his wife through treatment
options and recommends a tumor resection surgery called the Whipple procedure.
Thus far in the course, you have learned about preventative health care measures,
chronic disease management through care coordination principles of self-management
of disease, healthcare interoperability/HIT/EMR, motivational interviewing, and shared
decision making.
For the remainder of the course, you are going to apply what you know about medicalsurgical nursing, what you have learned about coordinating care in primary care
settings, and interdisciplinary team-based care to BTs case. You’ll use the care
coordination ring to identify the most important elements of BTs care as he prepares for
surgery and as he prepares to be discharged after his surgery.
(Ref. Care coordination and transitions between settings)
1. Research the Whipple Procedure in order to prepare BT and his wife for what’s
coming.
A. What are the indications for the procedure?
2. What are the risks and benefits of the procedure?
3. What are the steps of the Whipple Procedure?
4. What are the complications of the procedure?
5. What elements of Mrs. Smith’s medical and social history, and social
determinants of health predispose Mrs. Smith to poorer outcomes during her
hospitalization, post-surgery, and post-hospitalization? Why?
Medical and social
Why? Make the connections to poorer outcomes here
history, and social
determinants of health
Using the care coordination ring as a framework, answer the following questions.
Preparation – occurs pre-hospital:
A. What members of the HC Team will be involved in his pre-hospital
preparation?
B. What patient education does BT need and why is this information important in
BTs care?
C. What education and support does his wife (his caregiver) need and why is
this information important to her ability to take on this new role? Include perop and home care education.