Annie is a 69-year old Indigenous woman

Case Scenario
Annie is a 69-year old Indigenous woman who normally lives near her daughter Sharelle (who has three children) in the Atherton Tablelands in north Queensland. Her three grandchildren in Queensland are Sarah (12 years old), Kelly (9 years old) and Alex (3 years old).
Annie is passionate about being an Aboriginal community member, enjoying the yarning sessions and attending local community events. She is currently visiting her son Tony and daughter-in-law Kate in Melbourne (within the Monash Health catchment area). Together they have a 9-months old baby called Lily. Kate is returning to work, so Annie has come to Melbourne for an extended stay to help care for Lily. Annie loves seeing Lily, getting to know her, singing to her and taking her for walks.
Annie has lived independently for several years. She was employed as a Koori primary school teacher, which she loved. Annie retired three years ago to support her daughter Sharelle to care for her three children.
Annie has Type 2 diabetes and hypertension, which were diagnosed when she was 60. She has managed her diabetes with the support of the local Aboriginal Health Service. Annie had been informed that her kidney function was deteriorating, which she had been following up at the local Aboriginal Health Service. Shortly after arriving in Melbourne, Annie became unwell and was admitted to hospital. Annie is now diagnosed with Chronic Kidney Disease (CKD).
Annie was not keen on going to hospital, because she has never been in a hospital before, is not familiar with hospitals, and has friends and family who have had bad hospital experiences. On discharge, Annie has agreed to be referred to the local Aboriginal Community-Controlled Health Organisation (ACCHO), which is close to her son’s home.
Lizzie is the Aboriginal Chronic Care nurse who is employed by ACCHO. At the hospital, Lizzie speaks with Annie to confirm the referral and arranges to visit her at home.
Significant shifts have occurred over the last several decades in the policy and practice landscape of community and aged care services. As a consequence, the roles of the Registered Nurse and Registered Midwife have also changed in this practice context. An overview of Australia’s health system can be seen here.
This iSAP case reflects the changing health care needs of the Australian population and the growing need for PHC (Primary Health Care) in our health care system. The case is situated in the context of discharge planning and care transition from acute care to community care. Many different terms are used to describe this practice context including ‘discharge and transitional care’ and ‘transfer of care’.
The Victorian Government guidelines on Transfer of care from acute inpatient services, 2014 are aligned with the standards of The Australian Commission on Safety and Quality in Healthcare (ACSQH), The National Safety and Quality Health Service (NSQHS) Standards. Please familiarise yourself with these standards that inform quality and safety in the transfer of care.
As patient advocates and as vital members of the multidisciplinary and interprofessional care team, nurses and midwives play a critical role in facilitating the safe transfer of care across care settings and programs. Building on the themes of this unit (ageing and chronic and life limiting illness, PHC principles, clinical education, and EBP [Evidence based practice]) this assessment will help you to explore the important quality and safety considerations for practice in the transfer of care from acute inpatient services to community care.
Student Response
In preparing your Student Response (Part A of the case), please complete the following tasks.
1. Define ‘discharge planning’ and discuss the importance of discharge planning and care transition in relation to Annie’s needs. (approx. 100 words)
2. Briefly discuss two (2) known barriers to effective discharge planning in acute care services. (approx. 100 words)
3. Summarise in your own words and in dot point format 10 key steps for planning and implementing safe transfer of care as outlined in Transfer of care from acute inpatient services (2014). (approx. 250 words)
4. Construct a concept map that shows how you have drawn on Annie’s life story, health, environment, functional ability (physical abilities and limitations), and social wellbeing. The concept map should demonstrate person-centred care to the issues and improving her situation. Import (copy and paste) your concept map into your Student Response. (approx. 150 words)
5. Develop a care plan for Annie related to two (2) of her various health issues. Include the individuals and practitioners who will be involved. Use the table provided in the template (approx. 100 words).
6. Provide an EBP rationale for the following PHC principles (below) for Annie’s safe transition to community care. The rationale should include strategies from the National Aboriginal and Torres Strait Islander Health Plan (2021–2031) and the National Strategic Framework for Chronic Conditions (2017).

o cultural safety
o health literacy and self-management (for practical reasons these two principles have been combined)
o access to services
Presentation requirements:
• You are required to submit your answers in the templates provided for the Student Response (Part A) and the Student Report (Part B). The templates are provided as separate files in the AT3 assignment section. Do not change the structure of the template and do not delete the instructions in the template boxes.
• The instructions in the template boxes are not included in the assessment word count.
• The concept map must be legible with all information easy to read. It can be drawn or you can use the software provided under -Concept Mapping.-
• Use 11 font Arial.
• Use double line spacing.
• It is permissible to use dot point format in iSAP cases where asked.
• References are required for the Student Response (Part A) of this assessment.
• Submit in Microsoft Word format only; do not submit as a PDF or Pages document.
• You are required to use the APA 7 referencing in the unit.
• You must reference every statement of fact that is based on someone else’s work. In general, you should expect to use approximately one academic reference for every 100-150 words.
• Write within the suggested word count +/-10%. The word count includes in-text citations. The word count does not include the reference list or the instructions supplied within the the templates.

Discharge planning refers to the process of coordinating and planning the safe and timely discharge of a patient from an acute care setting to a community care setting. It is important because it ensures that the patient’s needs are met in a safe and appropriate manner, and that they are able to continue their care and recovery outside of the hospital. Discharge planning is particularly important for Annie, who is an older adult with chronic conditions and needs to be transferred to a community care setting that can support her ongoing care.

Two known barriers to effective discharge planning in acute care services are:

Limited communication and collaboration between healthcare providers, which can result in a lack of coordination in the discharge process.
Insufficient resources and staffing, which can lead to delays in the discharge process and inadequate planning.
The 10 key steps for planning and implementing safe transfer of care, as outlined in Transfer of care from acute inpatient services (2014) are:
Identifying the patient’s needs and preferences for ongoing care
Ensuring the patient has a discharge plan in place
Providing education and information to the patient and their caregivers
Ensuring that the patient has appropriate support and resources in place for their ongoing care
Ensuring that medication management is appropriately planned and communicated
Ensuring that relevant health information is transferred to the patient’s primary care provider
Coordinating the transfer of care with community care providers
Communicating the patient’s care plan and ongoing care needs to all relevant healthcare providers
Ensuring that the patient and their caregivers are aware of how to access ongoing care and support services
Conducting follow-up assessments and evaluations to ensure that the patient’s ongoing care needs are being met.
Please see the attached concept map.

Two health issues for Annie are her Type 2 diabetes and hypertension. The care plan for these issues will involve Annie, her primary care provider, and Lizzie, the Aboriginal Chronic Care nurse. The plan will include:

Regular monitoring of Annie’s blood glucose levels and blood pressure
Medication management, including ensuring that Annie is taking her medications as prescribed and providing education on potential side effects and interactions
Dietary and lifestyle modifications, including education on healthy eating habits and physical activity
Regular check-ins with her primary care provider and Lizzie to monitor her health and adjust her care plan as needed.
The rationale for the following PHC principles for Annie’s safe transition to community care is:
Cultural safety: As an Indigenous woman, Annie has specific cultural needs that must be taken into account in her care plan. Cultural safety means respecting her cultural beliefs, values, and practices, and ensuring that her care is provided in a way that is culturally appropriate and sensitive.
Health literacy and self-management: Annie needs to be able to understand and manage her health conditions in order to maintain her health and wellbeing. Health literacy means providing her with the knowledge and skills she needs to do this effectively. Self-management means empowering Annie to take an active role in her own care, by providing her with the tools and resources she needs to make informed decisions about her health. Strategies from the National Aboriginal and Torres Strait Islander Health Plan (2021–2031) and the National Strategic Framework for Chronic Conditions (2017) that can support these principles include culturally appropriate education and resources, community outreach and engagement, and support for self-management through the use of technology and other resources.

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