Care Plan: Helping Client and Family Make Transition

TO: All Staff

FROM:

SUBJECT: Recommendations for Helping Client and Family Make a Transition

DATE: 

As we can all understand, late life is a time of more than one transition. Transitioning is a hard task most especially for the patient and also to the family. Therefore we must all work towards making the transitioning process easier and a success. Ann is 82 years of age and her transition is undesired. This is the sole reason why we must all work together with her family in ensuring that she welcomes and takes her transition positively.

Ann’s case can be explained using the social reconstruction theory. This theory is founded on the concept that self-concepts heavily relies on the day to day interaction and the way other people react to them. However, in this theory, there are elements of social breakdown syndrome. This is the way an individual’s self-concept interact negatively with one’s social environment to produce a downward psychological functioning (Jin, 2010). This is the case with Ann who is quite vulnerable to psychological situations that require her to have a potential adjustment and coping approach.

Ann is vulnerable to breakdowns in a home and hence she has the greatest need for transitional care services. It is for this reason that we are all called upon to work together as a team in ensuring that Ann gets the best treatment during her time in the facility. We need to attend to Ann’s emotional needs during this transitional care. This will help in minimizing her negative experiences. It will also enhance her ability to support her loved ones most especially her daughter.

During this transition period, we ought to be proactive in our communication with each other, with the patient and her family. We should be able to explain the capabilities of the setting to which we shall place Ann during her caregiving. It is also important for us to be fully aware of the admission and the discharging process for Ann. We ought to work hand in hand with the facilities’ discharge planners. This will allow each and every one of us to have ready information for Ann and her family hence enabling them to be well informed. We ought to call the discharge planners regularly (Naylor & Keating, 2008). This will establish a relationship with them hence allowing for easier accessibility to Ann’s information update. However, it is important to note that communicating with Ann will be a challenge as she is angry at everyone. Therefore we should all try to build trust with her. This will allow her to open up hence creating a relationship with all of us with time.

Some of the most instrumental interventions for Ann’s case include the care transitional intervention and the transitional care model. Care transitions interventions will offer Ann and her family caregivers’ specific tools. This intervention will also allow Ann and her family caregivers to work with a transitional coach. Through this, they will be able to learn transition skills. Transitional care model, on the other hand, will be able to establish a multidisciplinary team (Naylor & Keating, 2008). This team will be able to work together in treating Ann’s chronological illness that is at high risk to self and to others. This team will give care to Ann during and after her discharge from the facility.

Yours sincerly,

References

Naylor, M., & Keating, S. A. (2008). Transitional care. Journal of Social Work Education, 44(sup3), 65-73.

Jin, K. (2010). Modern biological theories of aging. Aging and Disease, 1(2), 72–74. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2995895/