Coordinating Care for Adults With Complex Care Needs: Challenges and Solutions

Patient Summary

Identity: 85-year-old male.


The client is widowed, lives alone at home, and able to drive. Does not have a good social support structure, has two children, one works away and other lives interstate. Both the patient and the wife had been under community care for over three years, but since being widowed, over two years ago, the client has not been coping very well and has been experiencing a gradual decline in health.  

Medication: Aspirin 100mg, Metoprolol 50mg, Atorvastatin 10mg, Ramipril 10mg daily, Paracetamol MR 1330mg three times a day.   

Medical History: Heart Attack, recent fall, and dizziness.

Plan: Care plan review

Medical Issues

      The main issues noted include safety, depression/ loneliness, mobility, and dizziness. The safety issues are related to the dizziness and the patient not wanting to give up driving.  The patient has a history of heart attacks and is on a combination of antiplatelet and antihypertensives such as, Metoprolol, Atorvastatin and Ramipril. The dizziness could be secondary to the antihypertensives  that are currently prescribed (Olowofela & Isah, 2017). It is important to assess the times the patient has the dizzy spells and to adjust the medication accordingly, a daily sitting and standing blood pressure check is indicated. Drastic physical changes happen when people age, one of them is visual deterioration, in old age, eyes become less sensitive to light and refocusing from one object to another becomes longer and harder (Frank et al., 2021).

           Another issue is the poor mobility, the decline in mobility is expected in the elderly. Mobility issues in the elderly living in the community represent a preclinical transitional stage to a pathway to disability (Cruz-Jimenez, 2017). Studies show that individuals who lose their independence are less likely to remain in the community, have higher rates of disease, have a poor quality of life, and have greater chances of social isolation. Poor mobility often means that the patient is at increased risk of falls and frequent hospitalisation (Musich et al., 2018).  Decrease in mobility is a major contributor to the high rates of fall experienced in older adults, Studies show that even when injury does not happen, the fall can trigger a loss of confidence which leads to reduction in activity which further increases falls.

  (Musich et al., 2018). It is estimated that 1 in 3 older Australians have experienced a fall in the past 12 months with 1 in 5 requiring hospitalisation ( Australian Institute of Health and Welfare, 2020).  

         Thirdly, loneliness, depression, and social isolation. loneliness and social isolation are associated with poor health outcomes across all population groups. Studies show that the biggest contributing factors to loneliness is the death of a spouse, children moving away, loss of independence, fear of becoming a burden and a deterioration in friendship network (Reducing Social Isolation and Loneliness in Older People: 2017). Studies show that loneliness is associated with poor physical and mental health outcomes. With research suggesting they may even increase the likelihood of premature death. Loneliness has been shown to affect sleep patterns and increase levels of stress. Studies also show that loneliness increases the likelihood of accelerated cognitive decline and the onset of various forms of dementia, which in turn makes it hard to care for the patient in the community (Seyfzadeh et al., 2017).

Areas of Support

         The patient will be assessed using the I-CAN functional assessment tool. The I-CAN functional assessment measures the individual’s ability to perform self-care and physical activities. It also assesses the individual’s psychosocial, communication, and community involvement. This patient will be assessed on the ability to perform physical activities, sleep patterns, dietary habits, driving, and the ability to perform all the activities of daily living. this includes hearing, vision and digestive issues, social support structures and gross motor skills like mobility. The client will need assistance with four main critical areas these are, medication management, mobility, house modification and physical health ( Instrument for the Classification and Assessment of Support Needs – 2021).

          In dealing with safety, the patient’s living arrangement will need a review by the Occupational Therapist for recommendations on house modification and the necessary adaptation processes. Care planning must centre around the issues that arise because of a decline in mobility. Things to consider in this case is the installation of toilet rails, having a chair in the shower during personal care for falls prevention. It is important in this case to maximise the skills that the patient can already do and only help with tasks that the patient cannot do (Hyett et al., 2019). Post-fall, it is also good practice to have the patient reviewed by the physiotherapist to assess any physical limitation and to assess if the patient needs any mobility aids. Physiotherapists generally have an important role when it comes to working with the elderly, they are involved in preventing disease and disability, through symptom management. In this case, the role of the physiotherapist is the prevention of disability through nonpharmacological pain management like massages, heat/ cold treatment and dry needling and maintenance of muscle tone through stability exercises. A physiotherapist would also be able to come up with an exercise regime to help with falls prevention. Studies show that challenging balance exercises for two hours per week on an ongoing basis reduces falls risk in older adults living in the community (Falls Prevention Home_Exercises. 2021). In dealing with dizziness the physiotherapist would be able to conduct vestibular testing to work out if there something wrong with the vestibular portion of the ear and then come up with management plan. For example, Epley maneuverer is an effective nonpharmacological intervention for managing dizziness (Kowalska et al., 2019).

Role of a Coordinator.

         The role of the care coordinator is the efficient management of resources, in this patient’s case, the main role is to look at the big picture and to help the patient navigate through the health care system. The care coordinator is responsible for setting up appointments, sending referrals and implementing the changes. Another role of the care coordinator is to facilitate the easy access and share of information among professionals and all direct care workers. The care coordinator is also responsible for sourcing funding for the patient and to inform the patient of the resources available. It is the duty of the care coordinator in this patient to explicitly define the roles among team members and define the tasks and responsibility towards the patient, especially in a multidisciplinary care system (What Does a Care Coordinator Do, 2020).

         Finally, the role of care coordinator is decision support. Decision support refers to the delivery of up to date evidenced based patient centered care. It is important for the care coordinator to ensure that there no gaps in the knowledge among team members with regards to the latest best evidence practise.  Under decision support, it is the role of the care coordinator to provide continuous education to all team members, and to make sure that all their competencies are up to date. Continuous education and constant review of the policies to figure out what is working, ensures that the clinicians are using the best update practice guideline in patient care (What Does a Care Coordinator Do, 2020).

Care Plan

AssessmentGoalsDiagnosisPlanning       ImplementationEvaluation/rationale  
DizzinessThe client will stop filling dizzyDizziness likely related to cardiac issues and hypertensive medicationsDoctor’s referral for investigation on the cause of the dizzinessBlood panel, vestibular assessment.The client will not complain of dizziness.Investigation will be done for falls prevention and safety reasons
Safety IssuesThe patient will fill safe and supportedSafety issues Related to living alone and decreased in mobility and functional status  Doctor to assess the patient ability to drive.  Support services to help social mobility. Drive client to appointment. Drive client to adult day care centres.Help client with shopping.  The client has not missed appointments.The client gets to attend activities outside home regularly.  
Falls  To fill safe and not fallFall related to old age and the dizzinessPhysiotherapy referral for a fall’s management plan.Stability exercise, Strength exercises, pain management Dry needling.Massages.  Will not have falls Strength exercises help prevent falls.
Loneliness and depressionTo have daily medical, social and emotional supportLoneliness and depression related to being widowed and living alone.  To involve client in adult day care centres so that the client can socialise with other people  Silver chain to drive resident too and from the centres 3 times a week. Potable call bell in case of an emergencyThe client has been participating in community elderly activities on a regular basis and is enjoying them.To prevent rapid cognitive decline
House ModificationTo be safe while at home and alone.Related to living alone and dizziness.  Referral to the OT for house modification consultationInstallation of toilet rails. Paint house for easy navigation of surrounding. Shower chairs. Organise support staff.   Organise therapy assistants.  The client will feel secure and safe at home. For safety and falls prevention. Would allow client to remain in the community for as long as possible
Medication managementTo take medication on time.Related to decreased functional ability and history of heart attacks.Have the medication packed in web star pack and reminders set for when to take medication. Self-medication assessment to be done by GPEducation on importance of taking medication  Schedule a call every four hours to remind client to take medication. The times of medication must be charted during the times when care staff are visiting client.  The client will take medication every day. To prevent another heart attack. To prevent drastic functional decline.
Dietary managementTo have at least one hot nutritional meal a dayDietary issues related to living alone, being unable to cook and decrease in functional ability. Enrol of the services of SNAP to provide nutritional food for free.SNAP to deliver meals a once dayThe client will maintain a healthy diet. To prevent weight loss. Client does not have to think about food preparation.
Funding from the government for increased support.To source all the available fundingRelated to the patient needing more support in the way of community care.Assess the needs of the patient to set up a plan for care.  Application to my aged care for an assessment and to determine the funding structureThe client will have all funding available to them all year round.
Personal care needsTo have optimal oral and physical hygiene.Related to decrease in functional ability.Assistant nurses to help with some aspects of the client personal hygiene.Assistant nurse to visit client every morning to help client start the day. And to help with personal care.All activities of daily living will be attended to and documented in the progress notes.

Complex Care Model

            The complex care model used for this care plan is the Wagner chronic care disease model, the planning and intervention are all based on the physical, psychological, perceptual, and cognitive assessment that is done by the doctor and allied health care workers. The Wagner chronic care disease model has six main elements, these are the community, health systems, delivery systems designs, decision support, clinical information systems, and self-management support.  Self-management support aims at empowering the patient to take a lead role in managing their own health. Self-management support involves helping the patient in goal setting, providing compassionate and patient centered care, making referrals to community group and physiotherapy appointments. Self-management is a multidisciplinary approach and aims at tailoring the education specifically to the patient’s current condition.  The care plan will above is not rigid structure and will be subject to changes based on the condition of the client (Reynolds et al., 2018).

The Community

         On top of the professional care provided by the clinical staff and allied health care workers, the client would benefit from having community support groups like faith institutions and not-for-profit organisations to ensure that the patient is adequately supported. Depending on the assessment by the Doctor, and before any pharmacological interventions regarding the loneliness and depression, the patient should be encouraged to socialise and be informed of adult day care centres (Cheng et al., 2018). The purpose of these adult care centres is to encourage the elderly to socialise, engage in activities and eat a hot meal in a supervised setting. In Western Australia these centres are run by Silver chain, Silver chain can also provide support workers to drive the patient to and from these centres. These centres are also useful for families needing respite. Another community support group that the patient can benefit from is the SNAP. These are local charities that provide seniors with nutritional meals and the opportunity to socialise, these groups will in some cases provide free transport (Social Support For Seniors | Home Care Services Perth – Silver Chain, 2021).

Delivery Systems Designs

        This involves the creation of a system that enables professionals to know what care has been provided for the client. In this case, the use of regular progress notes is important so that all the professionals have access to the information, and to know what the other professionals have done and have been doing. Progress notes helps the care coordinator look at the big picture and figure out the interventions that have been effective and the those that are not.  An electronic medical information system would be ideal for this patient (Kharrazi et al., 2018).  In this system, only the professionals that have been given permission by the care coordinator to have access to the patient records can make changes and recommendations. Electronic systems allow for efficient delivery of care as any changes to patient care can be seen in real time and recommendations can be acted upon in a timely manner (Kharrazi et al., 2018). For example, some electronic systems will link all professionals together in a way that when the care coordinator makes a referral, other health care workers would be able to receive the referral instantly.  Delivery systems designs shifts the focus of delivering care from that which is reactionary to that which is proactive (Baumann et al., 2018).

 Clinical Informational Systems

              This is the use of clinical technology to provide information about the patient to all professionals directly involved in the care of the patient. Electronic information provides an easy access to information and to monitor the patient’s health status. It also makes it easier to share and coordinate information among professionals and enables the coordinator to monitor the performance of clinicians and the health care system (Morley & Cashell, 2017). It enables the care team to develop a patient-centred care plans and makes it easier to make changes to the care plan. There are about ten different electronic care systems available on the market, Matrix care would be ideal for community care patients. All professionals and support staff responsible for the care of this patient must download the program, it would then be mandatory to have at least one progress note after each visit. In this patient case having an electronic system takes the pressure away from the patient to constantly remember information or remember to health records to all appointments (Baumann et al., 2018).


         The above framework is used because it allows clinical staff to create a care plan that is tailored to the patient’s needs. It is a multilayered framework that takes into account, how information is transferred between professionals, community support workers and the family (Lall et al., 2018). The Wagner model is also ideal for individuals that are independent with most care and only need support for safety reasons and to prevent fast decline in functional status.   Community care in general allows for the client to choose and be in control of the services they want (Braillard et al., 2018). They get to eat meals they feel like and the type of support care workers they can have. This core principle of this care is self-management support, the Wagner model allows for the creation of services that feels in the gaps for the services that the client needs. For example, if the client still can drive and shower safely, then these activities should not be done for them for as long as it is possible to do so.


    This paper looked at the importance of care coordination in the efficient management and delivery of care. The complex care model used to formulate the care plan is the Wagner Chronic care disease model. The aim for this patient is to improve quality of life, through symptoms management and falls prevention.


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