Follow-Up Care Plan
Post-Discharge Client Needs
The client has significant needs regarding her abilities to complete ADLs, her mental
health status, and her economic standing. To ensure her needs are being met post-discharge, the
care team is responsible for making the client’s transition of care smooth and include minimal
obstacles for the client and her ability to access resources available to her care. Due to the
complexity of this client’s case, the follow-up care that the client will need includes the location
of discharge (home, nursing rehab, long-term care facility, etc.) as determined by physical
therapy, occupational therapy, and her medical team, establishing follow-up care with psychiatric
services, and set up a meeting between the client and her family and/or a human services
professional (HSP) with financial services to determine eligibility for financial assistance or
supplemental insurance and assist the client in applying for these programs along with
establishing payment plans for the services received.
Arrangement of Post-Discharge Services
The interdisciplinary team will arrange services by assessing the needs of the client that
are unmet. In this client’s case, the recommended services that should be arranged include the
level of care that the supervising medical staff determines the client needs then directing her to
resources or facilities that would be appropriate for her level of care and referring the client to
behavioral health services to treat her PTSD.
The client is noted to have significant mobility issues along with completing her ADLs.
With this, a referral to in-home health or a skilled facility is recommended for the client to have
, her healthcare needs met and be in a safe environment. Determining which kind of post-
discharge care is appropriate for the client is not within my scope of practice, however, I can
determine that due to her health, both mental and physical, the client is not able to safely care for
herself independently. Thus, a meeting with any physical therapists, occupational therapists, and
medical providers to discuss the appropriate discharge facility is required. Once the medical team
has determined where the client should be discharged to, the HSP and social work team can start
looking into different facilities and programs for that level of care to assist the client and her
family.
Due to the nature of the client’s psychiatric condition, following up post-discharge with
behavioral health services will help the client begin to process this traumatic experience healthily
and allow her to regain stability in her life. There are a multitude of therapy styles that have been
shown to significantly reduce PTSD symptoms; these therapy styles include Cognitive
Processing Therapy (CPT), Prolonged-Exposure Therapy (PE), and Eye Movement
Desensitization and Reprocessing (EMDR). CPT is a typically 12-session-long style of cognitive
behavioral therapy (CBT) designed for individuals with PTSD to restructure beliefs surrounding
the traumatic event. CPT is conducted in either a group setting or an individual setting and works
with the therapist to formally process the traumatic experience by questioning any unhelpful
beliefs regarding the trauma and modifying any maladaptive thought patterns or beliefs
(American Psychological Association, 2017). PE is another style of CBT that works to confront
fears and address traumatic memories and experiences. This is done through sessions with a
therapist where the client is recorded as they recite the traumatic event in detail using the present
tense (i.e. they are speaking as if they are actively experiencing it). After the client has recited
the event, the therapist and client work through any emotions that have arisen from discussing
Post-Discharge Client Needs
The client has significant needs regarding her abilities to complete ADLs, her mental
health status, and her economic standing. To ensure her needs are being met post-discharge, the
care team is responsible for making the client’s transition of care smooth and include minimal
obstacles for the client and her ability to access resources available to her care. Due to the
complexity of this client’s case, the follow-up care that the client will need includes the location
of discharge (home, nursing rehab, long-term care facility, etc.) as determined by physical
therapy, occupational therapy, and her medical team, establishing follow-up care with psychiatric
services, and set up a meeting between the client and her family and/or a human services
professional (HSP) with financial services to determine eligibility for financial assistance or
supplemental insurance and assist the client in applying for these programs along with
establishing payment plans for the services received.
Arrangement of Post-Discharge Services
The interdisciplinary team will arrange services by assessing the needs of the client that
are unmet. In this client’s case, the recommended services that should be arranged include the
level of care that the supervising medical staff determines the client needs then directing her to
resources or facilities that would be appropriate for her level of care and referring the client to
behavioral health services to treat her PTSD.
The client is noted to have significant mobility issues along with completing her ADLs.
With this, a referral to in-home health or a skilled facility is recommended for the client to have
, her healthcare needs met and be in a safe environment. Determining which kind of post-
discharge care is appropriate for the client is not within my scope of practice, however, I can
determine that due to her health, both mental and physical, the client is not able to safely care for
herself independently. Thus, a meeting with any physical therapists, occupational therapists, and
medical providers to discuss the appropriate discharge facility is required. Once the medical team
has determined where the client should be discharged to, the HSP and social work team can start
looking into different facilities and programs for that level of care to assist the client and her
family.
Due to the nature of the client’s psychiatric condition, following up post-discharge with
behavioral health services will help the client begin to process this traumatic experience healthily
and allow her to regain stability in her life. There are a multitude of therapy styles that have been
shown to significantly reduce PTSD symptoms; these therapy styles include Cognitive
Processing Therapy (CPT), Prolonged-Exposure Therapy (PE), and Eye Movement
Desensitization and Reprocessing (EMDR). CPT is a typically 12-session-long style of cognitive
behavioral therapy (CBT) designed for individuals with PTSD to restructure beliefs surrounding
the traumatic event. CPT is conducted in either a group setting or an individual setting and works
with the therapist to formally process the traumatic experience by questioning any unhelpful
beliefs regarding the trauma and modifying any maladaptive thought patterns or beliefs
(American Psychological Association, 2017). PE is another style of CBT that works to confront
fears and address traumatic memories and experiences. This is done through sessions with a
therapist where the client is recorded as they recite the traumatic event in detail using the present
tense (i.e. they are speaking as if they are actively experiencing it). After the client has recited
the event, the therapist and client work through any emotions that have arisen from discussing
