THE assessment meets the following learning outcomes:
1Cri?cally examine and evaluate the structure and func?on of integrated care services in suppor?ngand safeguarding adults with complex health needs and their families or carers 2Cri?cally analyse the physical and psychosocial requirements of adults with complex health needsand the challenges of addressing these4Work in partnership with adults who have complex health needs and collaborate with members ofthe inter-professional team and other agencies in order to posi?vely impact on the health andwellbeing of those in your careGuidelines for this Assessment? This is a 2000 word essay on your involvement in the multi-disciplinary team including the patients family or carers, when responding to their complex health needs. You should base this assignment on an individual you have nursed who encountered some kind of difficulty with their particular complex health needs that affected their health and independence.
? Your patient could have any coexisting physical and mental health problems or a learningdisability. Examples of physical conditions might be Diabetes, COPD, Parkinsons, MS, Stroke, Leg Ulcers, Pressure Ulcers etc. ? Your patient will quite likely have more than one condition, but for the purpose of this assignment and limitations of the word count you will focus on the holistic care provided, which should take into consideration health issues resulting from their respective comorbidities. However, remember that the main focus of the essay is integrated care, and the patient is used as a medium to relate and discuss this topic. ? You will concentrate on how you and your team were involved in inter professional team working, managing the patients care to restore independence to them (if and where possible).

The essay will identify a person with complex health needs, critically analyses and evaluate the ways the multidisciplinary team (MDT) were involved in planning integrated patient care needs, and discuss the nursing care provided , comparing this service provision with that recommended in policy and research findings linking this to partnership and inter-professional working, the MDTs effort in providing evidence based individualized patient care will be critically analyzed in relation to the academic and Government source literature and relevant local trust pathways,policies and guidelines.Susan is 72 years old; living with her family in a three-bedroom house, she has a past medical history of type ll diabetes, leg ulcers, heart failure and high blood pressure. Margret and her family manages her high blood pressure and diabetes well, she self-administers her insulin twice daily and go to her local surgery for blood pressure monitoring weekly, She was admitted to the ward due to fall and has since developed pressure ulcer on her heels. The hospital team worked together toensure that Susan received the best services in terms of integrated care to restore the health of the patient.? define integrated care. (few lines with ref)? health and social care act and local authority act ( few lines with ref)? implementing integrated care.? talk about the house of care.? Demonstrate how her needs have changed and what input she will need.? Talk about assistive technology like using telehealth and telecare in themanagement of hypertension and falls..,? Discuss legislations, Policy, frameworks, strategies and guidelines highlightingthe importance of integrated care and encouraged it implementation acrosshealth and social care
? Talk about how this how all this translates into the care provided for Susan.,? Talk about how the care was planned and who took charge of the plan ? The input of all the members of the MDTs both in the acute setting and in the primary setting should be outlined (how and what they did to assist Susan inher care) ? Go in depth as to how the need of the patient and what barriers there may beto establish the integrated care required and how this can be addressed, what are the strategies to ensure fairness and equality to every patient. ?
The last part should be a reflection on own learning and how it will improve future practice

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