Using the SBAR4 model for management of a patient with complex comorbidites in the home care setting - A case study

This home care case illustrates how the SBAR4 model can be used for a complex patient during a transitional care period to define the active problems at hand and the conditions needed to ensure successful outcomes of the management plans. Two home visits are described in this article: first, a home visit done after multiple hospital admissions for fluid overload and congestive cardiac failure; and second, a subsequent visit done after a fall with a resultant clavicle fracture impacting patient’s function and self-care abilities

Care Transitions in Complex Patients

Healthcare delivery is transforming from hospital-centric episodic care to a more patient-centric comprehensive and continuing care that caters to the changing needs of an ageing population and finite healthcare resources. The transition period during which patients move between healthcare settings is a period of vulnerability that requires well-executed care transitions. The relatively less-developed primary, intermediate and long-term care sector further underlines the importance of good transitional care. This article serves to introduce Family Physicians to the importance of transitional care, its broad concepts and a simple framework to help manage complex patients comprehensively in any Family Medicine practice setting.

Engaging the Family, The Family Conference

Family engagement should be part of a holistic management of any patient. This is especially so in patients who have an acute change in their health condition or function that stresses their social setup. Conducting a family conference is one of the many ways to engage patients and their caregivers and address their bio-psycho-social needs. It is a focused and purposeful approach that engages every member of the health care team and family members in facilitating a common understanding and decision-making with the aim of improving patient care and outcome. A family conference is resource intensive, and should be planned well to maximise the goals that it was set out to achieve. This article was written as a primer to help family physicians understand the indications, preparations needed, and steps to take in conducting a family conference. To facilitate a family conference confidently is a skill and an art that requires practice and constant refinement.

Discharge Planning from the Hospital to the Primary Care Clinic

Discharge planning is an integral component of transitional care. Patients need to have their care needs assessed early in the admission to put in place a robust care plan that can meet the medical, functional, and social needs of the patient. The care plan must then be clearly communicated to the next care provider as well as the patient and his caregiver to avoid gaps during transition across different settings and providers. For patients with complex care needs in the community, an intensive form of primary care far beyond what is offered in traditional primary care is needed. This can be achieved by being connected to the health system and resources, additional efforts in providing the care coordination to navigate the health system, and optimising clinical and social care around the patient’s needs.