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You are working in a long-term care facility with your client Mr. M that experienced a stroke leaving him paralyzed on one side with expressive aphasia. His health insurance coverage for long-term care is only 180 days (total) per calendar year. When Mr. M arrived, the team met to coordinate services with the goal to discharge him home before the180 day limit was reached. Evaluating and measuring his progress has been difficult as they have experienced multiple problems. This has led to Mr. M. being readmitted on one occasion then returning to the long-term care facility. You are the care coordinator and need to be current on what is, and has been, happening across all settings to make sure his care is equitable and of high value to his outcome.

Address the following question and provide evidence to support it from our course materials or outside readings in your main post.

1. Mr. M’s problems required a readmission to the hospital within the first 20 days at your facility. What are the economic issues for him? Could this be a breakdown of the care coordination team? What steps could have been initiated to maintain Mr. M’s health so as not to have to be readmitted?

The readmission of Mr. M to the hospital within the first 20 days at the long-term care facility raises several economic issues for him, including increased healthcare costs, potential loss of income due to prolonged hospitalization, and emotional stress. Additionally, if Mr. M’s health insurance coverage for long-term care is limited to 180 days per calendar year, this readmission reduces the amount of time he has left for rehabilitation and recovery.

The readmission may also suggest a breakdown in the care coordination team, as the team may not have identified and addressed all of Mr. M’s medical and social needs adequately. According to the National Academy of Medicine, care coordination involves “deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services” (National Academy of Medicine, 2019). Thus, if Mr. M’s care coordination team did not adequately organize and communicate among all parties involved in his care, this could have contributed to his readmission.

To maintain Mr. M’s health and prevent readmission, the care coordination team could have initiated several steps, such as:

Conducting a comprehensive assessment of Mr. M’s medical, functional, and social needs upon admission to the long-term care facility, and periodically throughout his stay, to identify potential issues that may lead to readmission.

Developing an individualized care plan based on the assessment, which includes specific goals and interventions to address Mr. M’s needs and prevent complications.

Implementing evidence-based interventions to prevent common complications associated with stroke, such as pressure ulcers, aspiration, and falls.

Coordinating with Mr. M’s primary care physician and other specialists to ensure that all medications and treatments are up to date and appropriate.

Engaging Mr. M and his family in his care and providing education and support to help them manage his condition at home.

By taking these steps, the care coordination team can help ensure that Mr. M receives high-quality, cost-effective care that promotes his recovery and prevents readmission.

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