After this discussing with my instructor she encouraged me to focus on one intervention (care coordination) that can be applied at the facility to reduce ER visit. The External evidence should be focused on evidenced based interventions or strategies that show care coordination have been successful in reducing psych ER visits in similar setting. Evidenced based guide lines on care coordination can also be implemented (No educational interventions). Evidence table will be strictly on care coordination (please check slide 4 and 5 of PP for more instruction). Let me know if you have any question. Please use the power point attached to this assignment and the comment under it as guidance.( I have rubric for the entire assignment for this semester so you can see the expectation but I want you to do the external and internal evidence first. The facility is a called People encouraging people in Baltimore MD (you can look it up to see what they are all about) I will be focusing on the patient in the PRP (Psychiatric Rehabilitation Program) PRP. It’s a day program, population of 170, age range 24-80yrs. Patients’ lives in different residential building with a counselors (not licensed) who assist them to ensure they take their medications, keep up with the residential rules and make sure they get ready and make it to the PRP day program. There is Case Manger that oversees case of load of patients. (1:20) There is a common nurse at the day program that oversees the medication and any clinical related issues Some problems highlighted by clinic: The Clinic does acknowledge there is a challenge in adherence to medication by the patients. The nurses at the clinic feel that counselor’s do not emphasize on adherence to medications and fail to conduct follow-ups to adherence to medication schedules for patients at the residential buildings. Lack of adequate patient data also due to admitting social workers failure to collect adequate patient information has contributed to inadequacy in planning for the patient management. Lack of coordination between the case managers and nurses before Patients are sent to emergency room visits.
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