CHAPTER 7

CARE COORDINATION FOR A PSYCHOLOGICAL/MENTAL HEALTH PATIENT

In this chapter, we use the Care Coordination Clinical Reasoning (CCCR) systems model as described in Part I and explain how the model can be used to reason about a case given the context of psychological/mental health. The case presented in this chapter illustrates how the advanced practice nurse works with a family that is in need of mental health and wellness services to promote quality-of-life outcomes. The provider/clinic is the point of access for patients/families. The advanced practice nurse provides care coordination through the application and use of critical-, creative-, systems-, and complexity-thinking processes to manage patient problems with an interprofessional team to design appropriate interventions and establish patient-centered outcomes. Depending on the nature of need involved in the case, referrals to other specialty or primary care providers or community services and living environments are determined and considered in managing care coordination and transitions (Haas, Swan, & Haynes, 2014).

The CCCR systems model framework begins with the patient story, which is derived from gathering data and evidence from an interview, history, physical examination, and the health record. The advanced practice nurse then develops a patient-centered plan of care using the Outcome-Present State-Test (OPT) model worksheets. In order to do this, one activates patient-centered systems-thinking skills for complex patient stories and habitually uses key questions to reflect on the specific sections of the model (Pesut, 2008), as well as the dimensions and elements of care coordination.

LEARNING OUTCOMES

After completing this chapter, the reader should be able to:

THE PATIENT STORY

We begin with the history and story of a 14-year-old White male, David Simms, who has a history of attention deficit hyperactivity disorder (ADHD) and bipolar disorder. David lives with his parents, who are his primary care providers, and one brother. His parents have concerns about his escalating mood swings, impulsivity, and aggression toward them, his stepparents, his brother, and select peers at school. His parents divorced when he was 8 years old and his mother has primary custody of him and his 11-year-old brother. He and his brother spend almost every weekend with their father and stepmother. He is able to identify one close friend at school.

David’s behavior problems started 1 year ago after he was hit by a car while riding his bicycle. He was thrown from the bicycle and hit the pavement head first. He was wearing a helmet at the time and it cracked on impact. His mother relates that “he does not listen to me and sometimes when I tell him to do things or try talking to him; he just stares off into space.” About 3 months ago, his mother found marijuana and drug paraphernalia in his bedroom. When confronted about the drug behavior, he firmly denied that he was using the marijuana and indicated that he “was holding it for a friend.” His parents describe that he had “normal” developmental maturation and had been an average student in school. During the past 2 years, he has barely been passing his classes.

During the interview, David had an angry affect and showed poor eye contact. He cooperated with the nurse practitioner, but adamantly stated, “I don’t want to be here.” His daily oral medications include Depakote 500 mg twice a day, Zyprexa 5 mg at bedtime, and Adderall XR 40 mg every morning.

PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS

Once the story is obtained from all possible sources, care planning and reasoning proceeds using the OPT clinical reasoning web worksheet (Figure 7.1), which helps determine relationships among issues and highlights potential keystone issues. The OPT clinical reasoning web is a graphic representation of the functional relationships between and among diagnostic hypotheses derived from the analysis and synthesis regarding how each element of the story and issues relate to one another. This activates critical and creative thinking. The visual diagram that results illustrates dynamics among issues and a convergence helps to point out central issues that require nursing care. As one thinks about this case, and begins to spin and weave a clinical reasoning web, relationships are identified among nursing domains and diagnoses as they are jointly considered with medical conditions. The psychiatric conditions in this case are history of ADHD, bipolar disorder, and comorbidities. Once the advanced practice nurse considers these psychiatric diagnoses, the nursing care domains associated with them are identified. The complementary nursing diagnoses most impacted in this case are dysfunctional family processes, interrupted family processes, ineffective relationships, and impaired social interaction.

FIGURE 7.1 Outcome-Present State-Test clinical reasoning web worksheet.

ADHD, attention deficit hyperactivity disorder; ICD-10, International Classification of Diseases, 10th edition.

To spin and weave the web, the provider uses thinking processes to analyze and synthesize relationships among diagnostic hypotheses associated with a patient’s health status. The visual representation and mapping of these relationships supports the development of patient-centered systems thinking and connections between and among the medical and nursing diagnoses under consideration given the patient story.

The steps to the creation of the OPT clinical reasoning web using the worksheet are as follows:

TABLE 7.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

ADHD, attention deficit hyperactivity disorder.

Source: World Health Organization (2015).

The OPT clinical reasoning web worksheet in Figure 7.1 shows a template with the patient health care situation, medical diagnoses, and nursing diagnoses at the center. Around the outer edges of the web are nursing domains with ICD-10 codes derived from history and physical assessment associated with the patient story. The directional arrows that create the web effect represent connections, explanations, and functional relationships between and among the diagnostic possibilities. As one can see, the domains and ICD-10 codes with more connections converging on one of the circles display the priority problem or keystone, in this case, problems related to relationships. A keystone issue is one or more central supporting element of the patient’s story that helps focus and determine a root cause or center of gravity of the system dynamics and helps guide reasoning and care coordination based on an analysis (breaking things down into discrete parts) and synthesis (putting the parts together in a greater whole) of diagnostic possibilities as represented in the web. Some key questions to ask here are: How does the clinical reasoning web reveal relationships between and among the identified diagnoses? To what degree do these relationships make practical clinical sense according to the evidence and patient story? Table 7.1 shows a summary of the connections highlighting the priority with the most connections.

TABLE 7.2 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-Test.

Adapted from Pesut (2008).

After considering the full picture using the clinical reasoning web worksheet, the next step is to use an OPT clinical reasoning model worksheet to facilitate and structure the patient-centered systems thinking about the care coordination of the identified problems highlighted in Table 7.1. As the advanced practice nurse thinks about the patient, she or he will concurrently consider the frame, outcome state, and present state. Each aspect of the OPT clinical reasoning model contributes to the other. The OPT clinical reasoning model worksheet is a map of the structure designed to provide an illustrative representation and guide thinking processes about relationships between and among competing issues and problems. Some questions that guide the use of the OPT clinical reasoning model are shown in Table 7.2 (Pesut, 2008).

By writing each element on the worksheet, all the parts of the model become related to each other. As the health care provider moves from right to left, the model structures the plan of care. Critical thinking skills are used to consider the patient story and creative thinking is used to identify and reason about the keystone issues/themes/cues to determine the most significant evidence in the present state. Complexity thinking helps the provider to consider the outcomes desired and the gaps between the present and outcome state. Once interventions and tests are decided, the plan of care transitions over to a care coordination model and team-centered systems thinking, which considers patient and family preferences within the frame of the situation.

The patient-in-context story (Exhibit 7.1) is depicted on the far right-hand side of Figure 7.2. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics; history of escalating mood swings, impulsivity, and aggression. He had an auto accident that resulted in a head injury and he has a diagnosis of ADHD and bipolar disorder. He also has a history of marijuana use. Assessment reveals an overweight 14-year-old with normal vital signs. Pertinent laboratory values show therapeutic levels of Valproic (108 mcg/mL), positive urine drug screen for amphetamines and tetrahydrocannabinol, and a normal lipid panel while taking Zyprexa.

A key step at this juncture is to review and reflect on the patient story for accuracy and thoroughness before proceeding with care planning for care coordination.

Moving to the left, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 7.2). At the bottom of this box is placed the designated keystone issue or themes that fall under the most significant nursing domain—problems related to relationships F93.8. Remember diagnostic cluster cue web logic is the use of inductive and deductive thinking skills. Some key questions to ask here are: What diagnoses were generated? Is there evidence to support those diagnoses? Is the keystone issue appropriate given this patient story?

In the center and background of the worksheet are places to indicate the frame or theme that best represents the background issues regarding thinking about the patient story (Exhibit 7.3). The frame of this case is a White adolescent male with an angry affect, poor eye contact, stating, “I don’t want to be here.” This frame (White adolescent male with psychological/mental health issues) helps to organize the present state and outcome state, illustrates the gaps, and provides insights about what tests need to be considered to fill the gap. Decision making and reflection surround the framing as the advanced practice nurse thinks of many things simultaneously. Reflective thinking is used to monitor thinking and behavior. Some key questions to ask here are: How am I framing the situation? Does the frame agree with the patient’s view of the situation? Given my disciplinary perspectives, what are the results I want to create for this person?

FIGURE 7.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

ADHD, attention deficit hyperactivity disorder; BMI, body mass index; BP, blood pressure; HR, heart rate; Ht, height; RR, respiration rate; Wt, weight.

At the center of the sheet are spaces to place the present state (Exhibit 7.4) and outcome state (Exhibit 7.5) side by side. The present state in this case shows six primary health care problems related to the keystone issue: defiant attitude, aggressive behavior toward family members, impulsive and aggressive behavior in school, marijuana use/abuse, recent diagnosis of bipolar disorder, and obesity. The outcome state shows six matching goals to be achieved through care coordination: parental support, behavior will be cooperative without aggression at home, behavior will be cooperative and attentive at school, no drug use, bipolar disorder is stable, and adheres to comprehensive nutritional meal plan. Putting the two states together creates a gap analysis that naturally shows where the patient is and what the goals are in terms of the patient’s care. A key question to ask here is: If the outcomes are appropriate given the diagnoses, are there gaps between the outcomes and present state and are there clinical indicators of the desired outcome state?

The gap between where the patient is and where the advanced practice nurse wants the patient to be is one way to create a test (Exhibit 7.6). Clinical decisions are choices made about interventions that will help the patient transition from present state to a desired outcome state. As interventions are tested, the advanced practice nurse evaluates the degree to which outcomes are or are not being achieved. The tests chosen in this case include: Vanderbilt ADHD Diagnostic Parent Rating Scale, Young Mania Rating Scale, urine drug screen, and body mass index (BMI) and growth-development charts.

Testing is concurrent and iterative as one gets closer and closer successive increments toward goal achievement. Some key questions to ask here are: How is the advanced practice nurse defining testing? On what scales will the desired outcome be rated? How will the advanced practice nurse know when the desired targeted outcomes are achieved?

 

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. The Evolving Nature of Nursing Process and Clinical Reasoning
2. Knowledge Complexity and Clinical Reasoning: Standardized Terminologies
3. Care Coordination for a Veteran/Military Patient
4. Care Coordination for a Maternity Patient

Stay updated, free articles. Join our Telegram channel

Join