Integrated Care Study Essay




The following essay is based on the case study of 80-year-old Agatha (not her real name, in keeping with the NMC's principle regarding patient confidentiality (Nursing and Midwifery Council 2015).  Agatha was accompanied to the clinic by her son to assess her cognitive decline. Over the past 10 months, Agatha has manifested short-term memory problems, and this has been a real concern to her family. Agatha had a fall 8 months ago; following that fall, her son reports that she began asking the same questions repeatedly. 5 months ago, Agatha had a second fall, as well as several episodes of dizziness over the past 3 months. Following these incidents, Agatha's her been seen to have suffered a further decline in her cognition. As recently as 3 weeks ago, her son reports that Agatha has become increasingly suspicious of his wife, and has began to hoard things. Agatha has also lost her enthusiasm in undertaking her daily activities. She often does not remember to incorporate the correct ingredients while cooking. Agatha has also been on medication for her hypertension for the past 10 years, and she also suffers from Osteoporosis and osteoarthritis. Her son and the rest of the family have to constantly remind Agatha to take her medication. Her son has also starting assisting in the management of Agatha's finances. People living with dementia along their carers often find it extremely hard to circumvent the intricate pathways of care required to receive the care and support that they deserve (Pratt, Clare & Kirchner 2006). For this reason, people with dementia, along with their carers, frequently lack a continuity of care. According to Bamford and Bruce (2004) this is likely to promote a level of confusion and anxiety in the already intricate day-to-day lives and activities of individuals with dementia and their carers. To avoid this, Glendenning et al. (2009) has proposed a more flexible and responsive form of integrated care capable of supporting the varied needs of dementia patients

Dementia care: Multidisciplinary team approach

            Health care professionals in clinical practice setting are advised to adopt a multidisciplinary and integrated approach in the diagnosis, care and management of dementia. This is because no single healthcare professional possess the knowledge and expertise required to address the intricate range of physical, emotional, physical, and social challenges  linked to dementia (The British Psychological Society 2014). The practicing clinician is often faced with unique challenges in trying to manage dementia. For this reason, it is important to embrace a collaborative team approach as it has been proven vital in providing effective care to people with dementia. A collaborative team approach relies more on integrating various types of therapies drawn from diverse community professional and healthcare providers, as opposed to over-reliance on standard pharmacological practice (Department of Health 2009).

            In order to implement the multi-disciplinary approach, it was important first for the clinician attending to Agatha to fully comprehend the disease processes, how the patient clinically presented with the condition, and to acknowledge the caregiving experience and its impact on patient care. In addition, the clinical had to first establish the resources available to the multidisciplinary team to enable it fulfil the social, emotional, and medical needs of Agatha within the family and community setting. While reliance on a multi-disciplinary team approach is quite intricate, on the other hand, it benefits the patient as well as the clinician.  For example, it enables clinicians to pay more attention to the issues that they deem as being most suited to their area of expertise, in addition to aiding in the management of the problems facing the patients and that could necessitate significant healthcare resources (Crooks & Geldmacher 2004).

             In caring for dementia patients, it is advisable to include support from diverse sources. Such sources could entails parallel, integrated, or a blend of the two. Caregivers and patients are also advised to seek for a mix of multi-disciplinary services consisting of various social service agencies, healthcare providers, as well as other professionals drawn from beyond the healthcare field.

            Multidisciplinary teams differ terms of their composition. Additionally, the structure of multidisciplinary teams could either be informal or formal. However, team construction is often determined by resources such as finances, time, availability, as well as geographical location. Irrespective of the structure, some of the key elements of successful teams include an acknowledgement of the role played by each team member and a shared commitment to providing quality care (Verhey et al. 1993; Keough & Huebner 2000). In line with the foregoing arguments, the multidisciplinary team attending to Agatha was largely determined by the availability of service resources as well as the cultural and social setting of the community (Crooks & Geldmacher 2004). In this case, team members who attended to Agatha included a neurologist, a neuropsychologist, nurse practitioners, social workers, occupational therapist and a nutritionist.  

            The neurologist was charged with the key role of making a formal diagnosis on Agatha's condition using validated practice guidelines and criteria. After diagnosis, the neurologist had to determine a prognosis and thereafter, formulate a treatment plan that would deal with the condition and its underlying symptoms (Crooks & Geldmacher 2004). In the event that the neurologist encounters certain uncertainties while making a diagnosis, it may be necessary to refer Agatha to a subspecialist who would proceed to refine the diagnosis, thus developing a workable care plan. Some of the dementia subspecialists include geriatric psychiatrists, behavioural neurologists, or neuropsychologists. In the case of Agatha however, it was not deemed necessary to  enlist the services of a dementia subspecialist because the neurologist was bale to arrive at a conclusive diagnosis. 

            The neuropsychologist helped to intepret the patient's quantitative cognitive performance data as drawn from the outcomes of a psychometric test. In addition, the neuropsychologist was also involved in offering continued support and therapy to Agatha and her family members (Manning 2004).

            The nurse practitioner attending to Agatha was charged with the primary role of assessing the patient's condition, in addition to managing her and the responses of the caregivers regarding the disease process. In particular, the practice nurse had to monitor Agatha's symptom presentation, respond to any issues on the patients medication, offer education and related information to the patient's family members, and helping them to get prepared for diseases progression.

            Since dementia often leads to reduced physical conditioning, immobility, poor coordination, and loss of tone and muscle strength, it was deemed necessary to include a physical therapists to the multidisciplinary team. Impaired ambulation is also reportedly common among dementia patients, and it increases the patient's risk of injury and falls. Considering that Agatha had fallen several times in recent months, the inclusion of a physical therapists would assist her to optimize her physical conditioning, in addition to maintaining safe mobility. Additionally, physical therapists can also reduce the dementia patient's need for institutionalisation by aiding in their prolonged independent living (Grand, Casper & MacDonald 2011). 

            In caring for dementia patients, social workers hinges their practice on the understanding that the person with dementia is a part of a larger system. In this case, the social workers assisted Agatha and her family to identify and obtain the resources required to manage the condition (Acton & Winter 2002). In virtually all cases, dementia patients and their caregivers shall need to access social services, including respite care, community programming, counseling support groups, financial services, and crisis management. Consequently, it is frequently recommended that a social workers be involved as part of the multidisciplinary team attending to a dementia patient once a formal diagnosis has been made (Crooks & Geldmacher 2004). In this case, the social worker helped to anticipate the patient's future needs, aided in the acquisition of services, and to helped the patient and her family navigate through the healthcare system.

            It was also necessary to include an occupational therapist as part of the multidiscpinary team attending to Agatha. This was deemed important as the occupational therapist would assist the patient and her caregivers to adapt to her diminished capacity to handle the challenges she is likely to encounter in her daily life.  For example, Agatha and her carers needed help in the use of various devices to assist her with eating, dressing, toileting, as well as with home management. An occupational therapist thus assists with enhancing the patient's independence and in this way, thus reducing the burden on the caregiver (82). Dementia is also associated with cognitive impairment, and this places the patient at an even greater risk for dehydration and malnutrition. The patient could also experience sensory motor impairments in the advanced stages of dementia, leading to the loss of ability to swallow and eat unaided. This leads to weight loss (Caron, Ducharme & Griffith 2006). For these reasons, it is necessary to also include a nutritional as part of the multidisciplinary team attending to the care and management of a dementia patient.

             Considering that Agatha also suffers from hypertension and osteoarthritis, it was deemed necessary to include  a nutritionist in order to address her dietary management concerns.  NICE (2006) recognises the principles of person-centred care as a fundamental component of good practice in caring for dementia patients. This is evidenced by the numerous recommendations that the guideline entail.  The fourth principles underscores the importance of taking into account the needs of carers in dementia care, be they family, paid care-workers or friends, in addition to also considering various means of supporting and improving their input to dementia patients. NICE (2006) has identified this as a form of 'relationships-centred care'.

             In treating and caring for Agatha, the multi-disciplinary team considered her needs and preferences. It is important to grants individuals with dementia an opportunity to make informed choices regarding the kind of treatment and care they receive. In this case, the multidisciplinary team acted as facilitators in ensuring that Agatha made an informed choice. The views of persons with dementia regarding who ought not and ought to be involved in providing care are essential and ought to be respected. With the consent of the individual with dementia, relatives and carers should get an opportunity to partake in decisions regarding treatment and care.  In the event that the patient is deemed to lack the capacity to made such informed decisions, it is recommended that the multidisciplinary team follow the advice on consent as spelt out by the Department of Health  namely, that all health care professionals should ensure that they obtain valid consent from patients regarding any examination, care or treatment that they seek to undertake (Department of Health 2009).

            The 2005 Mental Capacity Act recognises that every adult possess a right to make individual decisions but in the event that there is an impairment in their capacity to make decisions as often happens with patients with advanced dementia, the Act recognises that every adult reserves the right to receive reasonable support and help in making their own decisions (Office of the Public Guardian 2013). However, a capacity assessment conducted by Agatha's GP revealed that she had the capacity to make decisions. The social and health staff attending to Agatha made sure to consider the views of her family and carers as they described behaviour that might be relevant to dementia. Such information, along with an assessment of the patient, played a key role in making a diagnosis for Agatha, and in deciding on the kind of care that the patient received. The multidisciplinary team saw to it that good communication was maintained between care providers, the patient, their carers, and family. This was aimed at ensuring that Agatha received the support and information that she needed. It is important to ensure that evidenced-based information is provided in a way that is designed to fulfil the needs of an individual patient.


            My involvement in taking care of a patient with complex needs has made me appreciate the significance of a multidisciplinary team approach in patient care delivery. Working as part of the multidisciplinary team has enabled me to appreciate the need for team effort in providing the right care to the patient, at the right time and at the right place. Besides, the multidisciplinary team that I worked with consisted of among others, a neurologists, nurses, social workers, occupational therapist, and a nutritionist. Each of these professionals possess their own skills and expertise that is essential in managing and caring for a patient like Agatha with multiple health needs.  With a multidisciplinary team approach, we were in a better position to guarantee the patient and her family continuity of care, in addition to being able to undertake a holistic and comprehensive view of the patient's needs. It was also easier to attend to the patient's diverse needs because the multidisciplinary team attending to her possessed diverse educational and professional skills, and mutual support.

            Being part of this multidisciplinary team made me realise that such collaboration is not only beneficial to the patient, but also to the individual members of the team. For example, I realised that I could relate with some of the health care professional in the team on a professional and personal level because the multi-disciplinary team approach helped to break the communication barriers that usually exist between various health care professionals, thereby aiding in improved cooperation. Consequently, we were in a better position to provide better management and care to the patient, thus resulting in improved patient outcomes, increased job satisfaction, and improved patient, family, and carer satisfaction with service delivery. Taking into account these and other benefits of an integrated multidisciplinary approach in dementia diagnosis, management and care, it is recommended that such a practice be adopted widely. This is important considering that no one medical specialty possess the expertise required to cope with the intricate range of physical, social, and mental issues that usually accompany dementia.  While most clinicians find it quite challenging to share responsibility and integrate their professional expertise, a multidisciplinary approach results in enhanced continuity of care and management of patients with dementia, thus resulting in improved patient satisfaction.





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