Assessment
In reviewing an 85-year-old client with a non-healing wound, a complete medical history collection of the client is relevant. This should incorporate the documentation of past treatments made to the wound, such as surgical interventions or those made at home in terms of home regimens. The review of medical records should include all comorbid conditions in the client that may hinder the process of wound healing, such as diabetes, peripheral vascular disease, or immunocompromised status. The nutritional status and dietary profile should be assessed along with the client’s medical history. All these are necessary for the best results that complement the healing of any wound and depend on enough intake of essential nutrients: proteins, vitamins, and minerals (Hughes et al., 2020). Assessing a client’s dietary intake goes a long way in finding areas that might be potentially deficient or need optimization to enhance wound healing.
In addition, the client’s support system and living environment have to be assessed. This aims to ascertain whether the client gets assistance, even on matters relating to wound care at home, during daily living activities. It will also establish the level of support available to develop a holistic care plan, from medical to social needs, and ensure healing and total well-being. Third, such screening, there is a fact that it may easily cause Cognitive impairment or even psychiatric morbidity and might compromise the patient’s capacity to follow the treatment regimen or to present himself to medical care when necessary. Early identification of the prevailing cognition or mental health challenge would mean an early institution of appropriate intervention and support strategies to promote treatment adherence and improved outcomes.
Coordination of Care
Care coordination for the 85-year-old client would involve learning local services that relate to transportation. This can be done by community-based organizations, volunteer driver programs, or Medicaid transport services to assure the client that he can access such services even if the medical appointment is many miles away. Further, it ensures collaboration with the client’s primary care provider and local healthcare facilities (Hughes et al., 2020). This involves developing a collaborative care plan among the providers and opening lines of communication between them to allow provisions of care necessary to meet the general health goals.
In addition, the clients should be made aware of the available options for the money used to facilitate transport to be refunded. These may involve sharing with them about Medicaid transport benefits and mileage reimbursement programs, which take away financial hardships associated with travel to the clinic (Leithaus et al., 2022). This would reduce delays in accessing care services and give way to comprehensive service delivery within the right time frame since most patients have traveled far from remote areas and are affected by transport hitches.
Continuity of Care
In continuation of care to the 85-year-old patient, there are mobilization wound care strategies such as implementing a multidisciplinary approach that involves nurses, wound care specialists, physical therapists, and dietitians, among others (Leithaus et al., 2022). Such multidisciplinary collaboration assures the clients of individualized, comprehensive care. Moreover, the home advantage of a rural setting client relates to developed healthcare services or telehealth (Hughes et al., 2020). The services offer continued monitoring and support between clinic visits; hence, it will be possible to intervene in time and continue with continuity of care across the geographical divide.
The client should also be assigned an appropriate point of contact within the clinic. This would give the client a reasonable basis for any question or concern regarding his care and increase the continuity and access of the service (Leithaus et al., 2022). Such can include, for instance, implementing these measures whereby the client receives standardized and appropriate care and help with performing activities of daily living.
Social Determinants
The social determinants of this client are strong and greatly limit his access accessing optimal health care. Geographical isolation reduces available means of transport and may, therefore, result in failing to reach the clinic as required. Further, the financial constraint may add salt to injury, as the client may need more money to meet the cost of transportation to and fro and other supportive services. Social isolation and lack of social support may lead an individual to loneliness or depression that could be detrimental to the whole being and the capacity to perform activities. The social determinants must be well intervened in for his holistic well-being. Accordingly, the interventions may include organizational transportation aid, monetary aid or subsidies, and community-based outreach programs or support groups, which may reduce the person’s social isolation (Guest et al., 2020). Addressing the social determinants directly would place health practitioners in a better position to address the needs of their clients about access to the requisite care, hence improving the quality of life for their clients.
Education
Education remains an important component, whereby the client and family members have the power to participate in the non-healing wound management process, eventually leading to optimal healing. First, it involves teaching the technique of proper wound care. The teaching will include wound cleaning, dressing change, and descriptive signs for infection so that the client and care provider do it well at home. Nutrition and training on hydration are also key (Guest et al., 2020). A balanced diet rich in proteins, vitamins, and minerals is very important; it helps heal wounds from the inside since the body will have all the required nutrients to repair and grow tissues.
In addition, client education and the caregiver may also be necessary on preventive measures for pressure injuries to maintain skin integrity, especially for those with mobility impairment. This would include advice on how repositioning is done, the correct use of support surfaces, and skincare practices they would need to adopt to reduce the risk of pressure ulcers. Lastly, it is important to adhere to the wound treatment plan and remain for scheduled clinic visits to provide continued monitoring and management of the wound. This would support the client and his family in taking part in care actively since they would have been provided with the necessary information and skills that make it possible to heal the best and quickest wound and provide life support.
Conclusion
In summary, the developed comprehensive care plan for the 85-year-old client with a non-healing wound integrates integrated care, coordination, and continuity principles to achieve the best treatment outcomes. It further explains that it is a comprehensive assessment, coordination of care, socio-cultural consideration, and education meeting the client’s holistic needs—thus, an environment that will enable him/her to heal. Some of the barriers to access to care that can be alleviated through local transportation resources, shared care plan design with the primary care provider, and wound care and prevention education include: The social determinants, such as transport and financial constraints, will also go a long way toward adding to the level of access to care by the clients and promoting their general address. This care plan will, in essence, optimize patient outcomes in health and enhance a quality life product of patient-centered care and interdisciplinary teamwork.
Cited Works
Guest, J. F., Fuller, G. W., & Vowden, P. (2020). Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ open, 10(12), e045253.
Hughes, G., Shaw, S. E., & Greenhalgh, T. (2020). Rethinking integrated care: a systematic hermeneutic review of the literature on integrated care strategies and concepts. The Milbank Quarterly, 98(2), 446–492.
Leithaus, M., Beaulen, A., de Vries, E., Goderis, G., Flamaing, J., Verbeek, H., & Deschodt, M. (2022). Integrated care components in transitional care models from hospital to home for frail older adults: a systematic review. International journal of integrated care, 22(2).
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