Integrated Care for an Adult Living with Co-Morbidities












(The Date)






Integrated Care for an Adult Living with Co-morbidities


            Patients with co-morbidities necessitate the interaction of health professionals from diverse disciplines. This essay discusses integrated care for an adult patient with multiple underlying health conditions. In the accordance with the Nursing and Midwifery Code (2015) Trust, the paper will use a pseudonym in reference to the patient. Thus, the patient will be called Ivy. Ivy has been suffering from Type 2 Diabetes Mellitus over 40 years. In addition, Ivy is also asthmatic, a condition that she developed as a child. She currently lives with a colostomy bag after she was diagnosed with colon cancer the previous year and underwent a major surgery to remove the cancerous organ. She has been relying on inhaler to manage her asthma and tablets and hypoglycaemic and insulin shots to manage her diabetes mellitus. In addition, she is on medication to manage her depressive condition that she recently developed.  Ivy lives alone in a council flat where she has been managing her co-morbidities independently, although her daughter who lives nearby has been helping her. This means that health care providers must visit her at home to assess her condition and provide essential care. The essay will thus seek to explore the integrated care needs of the patient. Specifically, focus shall be on the role of nurses in caring for Ivy to ensure quality care. Because she is not hospitalized, she cannot enjoy the regular check up by professionals from different disciplines found in a hospital or hospice. Therefore, she would depend on a family member(s), community nurse, or herself to contact her doctors in case a need arise.

 Integrated Patient Care

            Ivy was provided with initial set of colostomy appliances and prescription information before she was discharged. The GP (General Practitioner) should know Ivy’s prescription information and document it in her medical records, so that he can issue prescription in the future. However, Ivy can demand change in the prescriptions based on her changing needs or emerging problem. A dietician would also be included in the team to guide Ivy on the correct diet that she ought to take to avoid developing complications with the colostomy pouch. Ivy also needs a special colostomy nurse to attend to her before and after the formation to help her choose the most appropriate colostomy appliance. Colostomy appliances can cause skin irritation, and can discharge repulsive odours. The stoma care nurse can  educate Ivy, her daughter and carer on most suitable equipment to manage Ivy’s colostomy effectively.

            Often, patients who have undergone colostomy are anxious that it will discharge smell and due to this concern, a psychologist will come in handy to dispel such concerns, and assure Ivy that others will not detect the smell, and that all this is only in her imagination. This professional will also help Ivy cope with anxiety resulting from excess wind and noise she will be discharging. The dietician can advice Ivy on diet that cause less wind.  While medicine are formulated to dissolve gradually in the GIT, colostomy should not change the success of usual medication. Nevertheless, if Ivy sees any tablets in her colostomy appliance, she should notify her pharmacist or General Practitioner to recommend an optional drug for her (National Health Service 2015).





            According to the National Health Service (2013), an integrated care is person-centred, coordinated, and tailored to the care needs and priority of the person, their family and carer. It entails moving away from episodic care to a more encompassing perspective to health, support and care needs. Such approach places the needs and experience of individuals at the centre of the way services are planned and delivered. Care co-ordination through integrated health and social care teams entails creating a more co-ordinated patient-centred care across care settings overtime, for patients with chronic co-morbidities who experience challenges in navigating fragmented health care systems (The King's Fund 2016). Based on the King’s Fund (2011), coordination of care for patients with multiple and chronic illnesses was poor, as supported by the Department of Health (2011) that those with long-term conditions had reduced life quality. To facilitate individual’s life quality, their care must be integrated. Consequently, team members include professionals from the home assessment re-ablement assistive living technologies (ALTS), adult care services assessment & care management, home care services, acute care, community care, and primary care (NHS England 2015). 

            After Ivy was first diagnosed with cancer of the colon, both she and her daughter were put in contact with a colostomy care nurse and were provided with the information on managing the prosthetic to ensure cleanliness. A plan of care was developed which could be reviewed and changed according to changes in the need of Ivy and her daughter, who provided support to her sick mother. Importantly, the plan included Ivy’s decision to live in her rental house as long as possible.

            The colostomy care nurse kept in close contact with the daughter and was copied in, at their request, to all correspondence to and from their General Practitioner, hospital consultants, practice nurse, diabetic team, and community psychiatry nurse to avoid the need to keep re-telling their story and to facilitate continuity in the care Ivy receives. The colostomy care nurse was able to organise a carer to stay with Ivy while her daughter was away. The daughter noticed that her sick mother was concerned about the absence of Yvonne, the carer.  So, the daughter spoke with one of the charities that colostomy care nurse had provided the information to her about, and the charity helped her purchase a laptop with a webcam and taught her how to install a video calling system, so that both Ivy and her could see and speak to the nurse and carer anytime they wished. Therefore, the carer had to have a laptop installed with the video calling system as well. 

            Providing integrated care necessitates a specific skill combination for professionals, allowing them to work in interdisciplinary teams and across conventional boundaries. Modification in workforce and education are essential to facilitating a move towards integrating care in community settings. A more flexible perspective is necessary so that staff can assume new approaches and responsibilities. For instance, the advent of new technologies such as telehealth and telemedicine will need new ways of working and new skills for general practitioners, nurses as well as carers (National Collaboration for Integrated Care and Support 2013).

            Research shows that the most effective examples of integrated care and the support of multidisciplinary teams have been those that recognized a select care-coordinator or case manager. King’s Fund (2013) asserts that care co-ordinators arose from a range of professional backgrounds and clinical experience. In other cases, care-coordinators involved directly in provision of care to Ivy, while sometimes, he would just facilitate multi-disciplinary care provided by other professionals. In providing integrated care to Ivy her nurse psychiatry was designated the care co-ordinator.

            The function of the care team formed to provide integrated care to Ivy could be described using a Continuum model proposed by National Health Service. Parallel to the constitution NHS, Ivy herself represents the integral part of the team. To facilitate the placement of team members on the continuum, the basic concept was explained to all the members by the GP. Team working eliminates the need for patients to see a procession of health practitioners, repeated investigations, and demarcations that hinder individual team members from achieving their authentic potential.

            In this case, the team applied trans-disciplinary continuum model where the barriers between different professionals dissipate and functions among the members are redesigned to make the best use of team skills and education. Assessment of the patient progress may be performed by different disciplines collaborating with understanding from one discipline informing the examination of another. The preferences of the patient will benefit from interdisciplinary perspective, and a learning culture in the team will take into account all perspectives. This is consistent with the NMC code of prioritising people  (Nursing & Midwifery Code 2015). Transdisciplinary working implies that one discipline may assume the traditional role another by consensus. Care coordination means that some teams create specific roles to facilitate team cooperation. This approach requires team members to integrate a component of their individual professional functions into the effort of the team. This team is non-hierarchical and often autonomous.

The composition of the team include diabetes consultant, clinical retinopathologist, GP, clinical nurse specialist, MDT coordinator, social worker, and two community nurses. The coordinator coordinates the MDT meeting for smooth running and coordination of information about Ivy. This key worker functions as an intermediate between the core MDT and wider community team to facilitate continuity of care. The views and feedback of the patient about care are considered in designing their care plan although they are not part of the MDT discussion.

The general goal of the service is to allow people with chronic conditions to be cared at home in order to die in preferred place and to avoid emergency admissions to the hospital during their last days. The central nurse specialist holds the responsibility for organising and co-ordinating care, whereas other members of the team maintain responsibility for their part of the integrated care. In essence, the care plan results from both formal assessment and informal discussions with Ivy, carer, the family member, nurses and GPs who are involved in the care of the patient.

Team Development

            Teamwork goes beyond team building. It is a philosophy or attitude concerning the mechanics by which organisations work. Teams of persons make key decisions instead of individuals, and these decisions are made at the closest possible point to the patient (NHS Engla nd/Nursing/LTC 2014). Teams undergo phases of development. In the mid-1960s, Bruce W. Tuckman  developed the most commonly applied framework for a team’s stages of development. This model provides a meaningful paradigm for assessing a team using his descriptions of forming, storming, norming, and performing.

            According to NHS England/Nursing/LTC (2014), every stage of team development has its own identifiable feelings and behaviours. Appreciating the why things happen the way they do in the team can be a crucial aspect of the self-evaluation procedure. The four stages outlined in the Tuckman framework helps in recognizing the behavioural pattern of a team; thus, they are most appropriate as a premise for team conversation, instead of problem diagnosis.

            Each stage of development in line with Tuckman’s  framework represents a meltdown of barriers to interdisciplinary coordination. In the forming stage, team acquaint and set up ground rules. It is characterised by individuals observing formalities and perceiving each other as strangers. Then individuals move to storming stage, when members begin to communicate their feelings although they still regard selves as individuals as opposed to team members, such that they resist control by team co-ordinators and express hostility.  At the norming stage, individuals feel part of the team and recognize that they can accomplish care by embracing each other’s views; in this case, even the patient is herself, her carers and family. In the fourth stage of team development, which Tuckman denoted as performing, the team operates in an open and trusting setting exemplified by flexibility and disregard of hierarchy.  In the final stage of team development, called the adjourning, the team carries out an annual assessment and adapts a plan for transitioning roles  and appreciating contributions of team members (NHS England/Nursing/LTC 2014 ). The team mobilized to provide integrated care and support to Ivy consist of both clinical and non-clinical individuals.  Despite this difference, these individuals can be united by an objective.

            According to the Royal College of Nursing (2009), a team needs explicit, shared and agreed objectives to be effective. Objectives contribute to the delivery of effective services for patients and their family. They provide a structure for the team to measure progress, recognise possible risks, and identify opportunities for team working. Setting objectives is essential to team members; it is actually the pillar of their unity. Goals help clarify the things or status that are crucial to members, care and those who use it.

            According to the RCN (2009), setting objectives is different from solving problem. In the latter case, teams and individuals often react to problems as they emerge. However, problem solving often leads to no change and as a result, the problem is often reduced rather than solved. Hence, setting goals is critical in delivery of integrated care.

            To create real improvement of the patient’s life quality and satisfaction of family or carers, the team should “begin with the end in mind”. They need to be very explicit regarding the current situation and what Ivy and her daughter desire. A clear team objective means that the team can choose actions to ensure it accomplishes the objective with time.

            Indeed, outlining objectives is rewarding on several accounts. Often, the process of setting goals offers opportunity to initiate discussion around the values of team, and to clarify whether individual members shared these values and to what extent. The process can depict the individual differences in the team that could impede the success of the team and jeopardise the quality of care received by Ivy. Such differences entail differences in understanding and views regarding the services the team provides, differences in role and responsibility perceptions, and difference in degree of accountability. While this process is complex, it is worthwhile.

            Once unifying team objectives were set, SMART principles will be observed to ensure the success of these objectives. This principle designates that a team objective must be specific, measurable, attainable, relevant, and time bound (Royal College of Nursing 2009).  Nancarrow, et al. (2013) recognizes trust and respect for self and others as epitome for collaboration. However, it takes patience, nurturance and time to establish a relationship that precedes any collaboration.


            People with multiple conditions have complex needs because of which their care should be integrated to ensure holistic delivery. Ivy condition necessitated the interaction of different clinical and non-clinical professionals in order to facilitate the best quality of life possible. Hence when caring for patients, it is crucial to take into account their needs and preferences. It also important for individual members of integrated care team shares the same objectives and all have the end in mind. They must respect, trust and tolerate one another in order to agree with each other objectives and work towards achieving them. Equally, a team must hold themselves accountable for achievement of the agreed upon objectives. From this learning experience, in order to integrate care for a patient with co-morbidities, it is expedient to ensure the needs and views of the closest family member, as they best understand and interpret the behaviours of the individual patient.







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