Simulated Patient Scenario

Transcription

1 Simulated Patient Scenario Scenario Title: Multidiscipline Care Plan Consultation for an Adult with Cognitive and Communication Impairment Location: Simulated Living Area Date: / / Subject/Course: Version: 2.0 Authors: Teresa Iacono, Kirrian Steer, Stephen Cousins, Sarah Down, Natasha Long Validated by: Estimated Duration Brief: 5 mins Simulation: 30 mins Debrief: 25 mins TOTAL TIME: 60 mins Learners: Medicine Undergrad X Nursing Post Grad Paramedicine Others (please list) Allied Health (state) X ExPhys, Sp. Path., Dentistry/ Oral Health, Social Work Background: People with intellectual disability experience marked health inequalities. They have high rates of health conditions that go untreated because of a failure to diagnose, or their conditions may be mismanaged. They experience high rates of chronic health conditions and health risks (e.g., obesity, poor nutrition, and limited physical activity), but often do not engage in preventative health care, beyond those mandated by disability services (e.g., annual flu shots) for those living in disability supported accommodation (i.e., not those living with family). Their communication impairments can act as a barrier to good quality health care. Such impairments can lead to health care practitioner difficulties in obtaining a case history, relying on a family or paid carer to report the person s symptoms, and concerns about a patient with intellectual disability s ability to follow a management or treatment plan. There is also a tendency towards diagnostic overshadowing in the delivery of health care to people with intellectual disability: that is, the incorrect attribution of signs or symptoms of health (or mental health) problems to a person s primary disability.

2 People with intellectual disability, therefore, often have complex health conditions that require the input of a multidisciplinary team. General practitioners who have an awareness of their health inequalities or who simply follow patient centred care practices, regardless of whether there is a primary disability, can co ordinate a multidisciplinary care plan. Scenario Overview: Referral: An Accredited Exercise Physiologist (AEP) receives a GP s referral to conduct a health screening/fitness assessment for Jason (reported issues with weight, diabetes risk, and cardiovascular risk, and lower back pain). He has also been referred for speech pathology (SP) assistance with his communication difficulties. Scene Setting: The AEP and SP work at the Bendigo GP SuperClinic. The GP requested that the conduct a joint consultation as it is more convenient for Jason and his mother. Setting: Simulated Living Area set up as EP consultation room Competencies demonstrated in this scenario include: Skills AEP SP 1. Apply published pre exercise screening tools to risk stratify participant. 2. Select, perform and interpret appropriate health and fitness assessments for individual with cognitive and communication impairment. 3. Communicating effectively and respectfully with a client and family carer 4. Perform OMA and interpret information 5. Communicate effectively and respectfully with a client and family carer 6. Identify and refer to required health services Behavioural Orientation and Personal Traits 1. Takes Initiative 2. Compassionate and empathetic approach 3. Problem solving 4. Confidence in own ability 5. Builds rapport 6. Interpersonal skills

3 Participant Brief: Exercise Physiologist You work at the Bendigo GP SuperClinic. One of the GPs has referred a patient to yourself and a speech pathologist who also works at the clinic. The GP has also requested that you conduct a joint consultation as the patient has a both a cognitive and a communication impairment. In attendance will be Jason (the patient), Pam (his mother/carer), the speech pathologist and yourself. You may discuss your preferred approach to the consultation with the speech pathologist. A copy of the referral and patient history has been provided for you to review. During the consultation you are required to select and administer a pre exercise screening tool and then if appropriate, conduct and interpret an appropriate health and fitness assessment of the patient. If you identify that the patient would benefit from the expertise of another health professional, you should communicate this to the patient and his mother, and make appropriate arrangements to ensure continuity of care. Speech Pathologist You work at the Bendigo GP SuperClinic. One of the GPs has referred a patient to yourself and an exercise physiologist who also works at the clinic. The GP has also requested that you conduct a joint consultation as the patient has a both a cognitive and a communication impairment. In attendance will be Jason (the patient), Pam (his mother/carer), the speech pathologist and yourself. You may discuss your preferred approach to the consultation with the exercise physiologist. A copy of the referral and patient history has been provided for you to review. During the consultation you will be required to conduct an oral musculature assessment (OMA) and assist the patient with communication if required. It is suggested by the GP that you perform the OMA after the exercise physiologist has completed his assessment. This way you can gather as much information as possible through observation and minimise the need for duplication of questions/assessments. If you identify that the patient would benefit from the expertise of another health professional, you should communicate this to the patient and his mother, and make appropriate arrangements to ensure continuity of care.

4 Expected Scenario Sequence: Jason attends with his mother, Pam, an elderly woman. The AEP conducts his assessment with communication support provided by the SP. AEP assessment: 1. AEP to initially perform a health appraisal and risk assessment using a pre screening health questionnaire (ESSA Adult Pre exercise Screening Tool). Following the health screening and risk assessment, AEP conducts an assessment of body composition, including height and weight for BMI and waist and hip circumference. 2. AEP then conduct an assessment of cardiorespiratory fitness via a 6 minute Astrand Rhyming cycle test. 3. AEP finishes assessment with an assessment of muscular fitness (i.e. arm curl or push up test) and flexibility (sit an reach, straight leg raise). 4. Throughout the assessment, communication and understanding of instructions is an issue and SP steps in to assist. Speech Pathology Assessment 1. Noting Jason s responses to the AEP s instructions. 2. Steps in to provide cues if Jason demonstrates he has difficulty understanding the AEP. 3. Observes a lot of drooling from one side of Jason s mouth. She asks about his eating and drinking and learns that Jason does not like taking the Panadol Osteo recommended for his back pain, and sometimes gags on them. 4. Conducts an Oral Musculature Assessment. Jason draws his head away as she approaches with a tongue depressor to test his gag reflex. He says ow when she touches his lower jaw. 5. The SP notes some redness of his gums when she is finally able to look into his mouth. 6. The SP asks when he last saw a dentist. Pam says she can t remember, as she can t afford for either of them to see a dentist.

5 Information for the Simulated Patient The aim of this session is for students from different professions to Work together Be able to explain what they want you to do Ask you questions so they can find out if you have some problems with your teeth or gums Explain what they think should happen after the session. You have been asked by your GP to visit an exercise physiologist and speech pathologist. Your doctor is worried about your weight and your low back pain. He wants the exercise physiologist to assess your physical fitness. He also wants you to take some pain killers for your back pain. But you hate taking tablets because sometimes you cough them up because they are hard to swallow. You go to a clinic where you see the exercise physiologist and speech pathologist in the one appointment. Your mother Pam is with you. The exercise physiologist will ask you questions about your health and lifestyle. They will then ask you to do some sit ups or push ups, pedal on an exercise bike, and will measure your height, weight, and around your waist. You have trouble understanding what the exercise physiologist is wanting you to do. You won t do what s/he asks you to do, but if the exercise physiologist asks if you understand, you will say Yes, (but still won t do anything). When the exercise physiologist shows you what to do, you are able to do it. After the exercise physiologist has finished, the speech pathologist will talk to you. The speech pathologist will ask about your mouth being very wet on the side. You will say that sometimes your mouth hurts. S/he will ask to look in your mouth and to make some sounds. S/he will show you and you will do what s/he is doing. If s/he touches your mouth, the inside of your mouth or your teeth, you will pull your head away and say ouch. The speech pathologist will ask you or your mother if you have been to see a dentist lately. You will say no if she asks you directly. Information for Simulated Carer While Jason is being assessed by the exercise physiologist and the speech pathologist, you will sit and watch, and occasionally make a comment like, oh, he doesn t do a lot of exercise, or he is pretty strong, just like his dad was.

6 If the exercise physiologist or the speech pathologist asks you a question rather than asking Jason, you will say Oh, think you had better ask him that, or something else to redirect the clinician back to Jason. When the speech pathologist suggests that Jason see a dentist, you are very worried and let her/him know that that will be very expensive and Jason does not have the money to pay for it. Patient s history of the problem: Is overweight Does outside work, such as pushing a lawn mower and sweeping paths Patient s Past Medical history: Has had lower back pain intermittently for 5 years (since starting work at RES) Patient s Family History: Father had type II diabetes, died 3 years earlier from heart attack Mother is frail has circulation problems making mobility difficult Patient s Social Information (Work, Lifestyle, Habits): Been working at Radius RES for 5 years Works 3 days/week but work varies according to job requests and weather Spare time spent largely watching TV or playing games on his ipad Likes to eat take away food, but mother limits this to one meal a week

7 Considerations in playing this role including wardrobe, make up and challenges:

8 Scenario Observation Notes: Notes on scenario events, additional learning points Debriefs Scenario Participants (Students, Simulated Patient, Simulated Mother) What went well? Why? What didn t go so well? Why? How could things be improved? Students only (Simulated Patient and Simulated Mother have left) How did you feel in interacting with the patients and his/her mother? What would have made you feel more comfortable in the situation? Were there any particular challenges for you in this scenario? Debrief for Observer Students: What did you think about the communication between the students, the patient and his/her mother? What did you think about the communication between the students? What did you think about the teamwork between the students? Workshop (in small groups with post it notes and butcher s paper used to gather student ideas): Students will work in groups of mixed disciplines and discuss the role of their own discipline in terms of what should happen next for this patient and his/her mother. What particular reasonable adjustments to usual practice, the set up of the room, etc. might be needed to support this or other people with intellectual disability? What are the next steps for Jason/ Jane or his/her mother? What is the role of your profession in supporting the health of Jason (or Jane if a female scenario)? What other profession could be involved, and to what extent would you work with that other profession(s)?

9 Resources/Appendices: Appendix 1 Brief to participants Appendix 2 Information for Participants (background information, pre reading, patient notes) Appendix 3 Assessment instruments/evaluation Acknowledgements This template is a modified version of a template developed by Prof. Debra Nestel, Monash University. Character Attributes table modified from Pascucci, R. C., Weinstock, P. H., O Connor, B. E., Fancy, K. M., & Meyer, E. C. (2014). Integrating actors into a simulation program: a primer. Simulation in Healthcare, 9(2),

10 Appendix 1 Participant Brief When briefing participants the following must be addressed: Safety/Risk considerations Confidentiality (Agreement is signed by each student) Safe learning environment Use of video/photography Formative/Summative assessment/no assessment Disclosure of scenario events: o Students may try to predict the scenario events and will wait for the patient to crash. This can derail the scenario. Make sure that for simple scenarios that you disclose that there will be no emergency, that there are no tricks and that they are not being set up. The task that they are given in the briefing is all that is required of them. o If there is an unexpected event in the scenario, give a broad description, such as disclosing that the scenario is about clinical reasoning and that they will be required to respond to the patient s situation. Orientation to setting and equipment

11 Bendigo GP Superclinic Date: 28/09/2015 Dear Exercise Physiologist Re: Jason Collins DOB <insert DOB> This patient has attended a consultation with Dr Thompson for the purpose of having a care plan drafted for chronic disease management. Recent examination findings demonstrate BMI 32 Mild lower back pain Our service strives to improve health outcomes and ensure the patient is receiving optimum and integrated health care. The patient has signed a consent form, permitting us to enquire about and receive information relevant to the health intervention they have, or have planned to have, which may have a bearing on our objective. Attached is a copy of the Care plan and/or pathology reports. Please supply further feedback once treatment has begun. Thank you, Practice Nurse Bendigo GP Superclinic 45 Main St Bendigo VIC 3550

12 GP Management Plan (Item 721) Patient s name: Jason Collins Patient s Date of birth: <insert DOB> Contact details: Medicare number: 23 Walsh St /3 Bendigo VIC Details of patient s usual GP: Details of carer (if applicable): Kim Thompson Pamela Collins 45 Main St 23 Walsh St BENDIGO VIC 3550 BENDIGO VIC Date of last Care Plan/GP Management Plan (if done): 28 September 2015 Other notes or comments relevant to the patient s management plan: Jason has an intellectual disability and lives at home with his mother Pam, who is his carer. Jason reports lower back pain since beginning horticulture work 5 years ago. Pam is concerned about Jason s weight gain and impact on back pain/health. Past Medical History: Intellectual disability unknown aetiology Medications: Drug name: Strength Dosage Reason Last script Panadol Osteo 665mg prn back pain 12/05/2015 Allergies: Nil known Warnings: None recorded Smoking: None recorded Alcohol:Unknown NEED GOAL ACTIONS PROVIDERS REVIEW DATE Weight management 28/09/2015 BMI=32 Aim for BMI < _25 kg/m 2 Increase physical activity Appropriate diet GP AEP 3-6 months Manage back pain Communication Aim for full work duties Improve ability to communicate with others Review physical activity levels & manual handling Rehabilitation exercises Investigate use of electronic communication aids eg Apps on ipad GP AEP GP Speech Pathologist 3 6 months 6-12 months

13 Assistance with daily living activites Preserve/optimise independence Assistance in the home/other Support services GP to advise and monitor Copy of GP Management Plan offered to patient? YES Copy/relevant parts of the GP Management Plan supplied to other providers? YES GP Management plan added to patient s records? YES Date service was completed: 24/07/2014 Proposed review date:24/10/2014 I have explained the steps and costs involved, and the patient has agreed to proceed with the service. YES GP s signature Date: 24/07/2014

14 Team Care Arrangement (Item 723) Patient Copy Patient Name: Jason Collins HEALTHCARE PROVIDERS ON THIS TEAM Care provider Type of care Appt date and time Contact Details Kyle Walker Exercise Physiologist Kyle Walker Bendigo GP Superclinic 45 Main St Bendigo 3550 Ph: Joanne Singer Speech Pathologist Joanne Singer Bendigo GP Superclinic 45 Main St Bendigo 3550 Ph: I have explained the steps and costs involved, and the patient has agreed to proceed with the service. YES GP s signature Date: 28/09/2015 I have understood the steps and costs involved, and agree to proceed with the service. Patient s Signature Date: 28/09/20015 Jason Collins Date TCA Completed: 28/09/2015 Proposed TCA Review date: 28/12/2015

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