Jane Doe is a 70-year-old female patient. She is 5’2” and weighs 125 lbs. She has several major issues in her past medical history, including high-cholesterol and osteoarthritis. In May 2018, the patient had a right knee replacement surgery due to osteoarthritis and though it was rather major surgery, she had no complications and normal recovery. Eight years ago, the patient had right meniscus repair. In addition to knee trouble, the patient also had kidney stones which were treated with shock wave lithotripsy. Finally, she had basal cell carcinoma of the philtrum, which was surgically removed. While the patient has had several significant health issues, they are not beyond what is to be expected of someone of her age. She follows up with her dermatologist and urologist yearly.
A comprehensive health assessment is dependent upon a quality interview of the patient. The clinician conducting the interview must have solid communication skills in order to effectively engage the patient in discussing their health openly and honestly. It is therefore important that to use evidence-based interviewing techniques in designing the questions and conducting the interview in order to ensure that it is effective. These interview techniques have been demonstrated to effectively engage the patient to generate the most useful information about health and the environmental, social and personal factors that impact it. Studies have shown that using a patient-centered model for interviewing is more effective than focusing narrowly on diagnosing (Hashim, 2017). Four techniques of patient-centered interviewing were used in interviewing the patient: active listening, adaptive questioning, displaying empathy and nonverbal communication.
Active listening. Active listening requires the nurse or clinician conducting the interview to be fully attuned to the patient during the interview (Bickley & Szilagyi, 2012). For instance, the nurse should avoid engaging in distracting activities during the interview, such as updating the patient’s chart while she is talking (Hashim, 2017). The person conducting the interview should also occasionally summarize what the patient says to demonstrate that he or she is listening to the patient. This also allows the interviewer to ensure that they fully understand what the patient is communicating.
Adaptive questioning. It is important for the interviewer to begin with a set of standard questions when conducting a comprehensive health assessment. However, it is equally important for the interview to be flexible. Using an interviewing technique called adaptive questioning allows the interviewer to elicit more information from the patient by asking follow-up questions based on the patient’s response to standard questions (Hashim, 2017). This technique helps the interviewer elicit additional information from the patient that otherwise would not be revealed by the standard interview questions alone.
Displaying empathy. It is crucial for the interviewer to display empathy when conducting the health assessment interview. Empathy refers to connecting with the patient on an emotional and intellectual level (Hashim, 2017). This interview technique reassures the patient that his or her personal story is important and that the interviewer sees the patient as a unique individual, not just a collection of health issues and symptoms (Hashim, 2017). Displaying empathy creates a sense of trust between the patient and interviewer, which elicits more honest and complete information during the health assessment interview.
Nonverbal communication. Using nonverbal communication is an important technique for conducting a comprehensive health assessment. Using effective nonverbal communication has been shown as a way to collect more relevant data from the patient during a health assessment interview (Hashim, 2017). The interviewer should communicate to the patient that they are actively listening and interested in what is being said. This can be achieved by nodding the head, making sure that the facial expression communicates attentiveness and leaning forward (Hashim, 2017). The interviewer should avoid crossing the arms and interrupting the patient.
The four evidence-based interview techniques described above were utilized in the health assessment interview. The questions asked were also based on a set of standard principles for interviewing.
Key questions and justification. There is a large body of evidence that social and environmental factors play an important role in an individual’s health. Therefore, it is necessary for a comprehensive health assessment to include questions related to the patient’s cultural, social and economic environment (University of New England, 2019). The following questions, based on the Iowa State Innovation Model (2016), were asked to uncover the social determinants of health related to economic security that impact the patient:
• Do you have difficulty paying for basic necessities like food, housing, medication, and healthcare?
• In the past year have you or your family had trouble accessing food due to cost or the absence of food availability in your neighborhood?
• What is your current living situation: homeowner, renter, resident of an assisted living facility or senior community, or living with a family member?
• Do you have any of the following problems related to your housing: rodents or bugs, general state of disrepair, mold or other hazards, the threat of eviction?
• What is the highest level of education you attained?
A comprehensive health assessment should also uncover any factors that are associated with health disparities based on race and ethnicity. Individuals from racial and ethnic minorities have overall poorer health outcomes than white Americans, constituting a persistent disparity in health (AHRQ, 2019). The Health Research and Educational Trust (HRET) provides a comprehensive list of questions for assessing a patient’s racial and ethnic background, as well as language abilities and any disabilities (HRET, 2012). For the purpose of this assessment the following questions were asked in order to determine if the patient is at risk for health disparity due to race, ethnicity or disability:
• Do you consider yourself to be of Hispanic, Latino or Spanish ethnicity (HRET, 2012)?
• What racial/ ethnic group do you primarily identify with: African American/ Black, White, American Indians/ Alaskan Native, Asian or some other race (HRET, 2012)?
• Are you hearing impaired or do you have any other disability (HRET, 2012)?
In addition, the following questions were asked in order to determine if there are any cultural factors that should be taken into consideration in assessing the patient’s health:
• Are there cultural or religious practices that you consider important to your health (AHRQ, 2012).
A comprehensive health assessment of seniors must also take into considerations issues related to mental and emotional wellbeing (AHRQ, 2013). The following questions drawn from the AHRQ guidelines for health assessment of adults were asked in order to determine the patient’s general mental health status:
• Over the last two weeks, how often have you found yourself feeling nervous or anxious?
• How many times have you had difficulty controlling your fears over the past two weeks?
• How often have you felt depressed or hopeless over the past two weeks?
• Have you experienced a lack of interest or pleasure in activities over the past two weeks?
• How often do you feel extreme levels of stress?
• Have you ever misused prescription drugs or illicit drugs? If so, how recently?
• Do you use alcohol or tobacco? If yes, how frequently? (AHRQ, 2013, pp. 37-38).
Studies have shown that a strong social support network helps improve seniors’ physical and mental health. A comprehensive health assessment should, therefore, take into consideration what type of social support the patient has. Participating in a religious or spiritual group has also been shown to improve overall wellbeing in seniors (Sowa, Tobiasz-Adamczyk, Topór-Mądry, Poscia & La Milia, 2016). The following questions were asked to determine the patient’s level of social support:
• Do you feel like you get the emotional support you need from friends and family (AHRQ, 2013)?
• Is there a friend or family member or someone else in your community who you can turn to for help in addressing your problems (HRET, 2012)?
• How often do you spend time with your family or friends?
• Do you belong to any clubs or recreational teams?
• Do you attend any religious or spiritual services regularly?
An individual’s neighborhood and physical environment are major determinants of health (AHRQ, 2013). The following questions were asked to generate an understanding of the environmental factors affecting the patient’s health:
• Do you live in an urban or rural neighborhood?
• Do you have access to affordable transportation?
• Is there access to medical services near where you live?
• Do you have access to healthy food in your neighborhood?
• Do you feel safe living in your neighborhood?
• Do you feel threatened by crime in your neighborhood?
In addition to asking the patient about things related to social determinants of health, a comprehensive health assessment must generate a picture of what the patient’s everyday life looks like (AHRQ, 2013). The patient’s quality of life depends in large part on their ability to live independently. The following questions, based on AHRQ guidelines, were asked to assess the patient’s overall health and ability to function independently:
• Over the past two weeks, have you needed help to perform any of the following activities: walking, going to the bathroom, dressing, bathing, grooming or eating?
• Over the past two weeks have you needed help conducting any of the following activities: shopping, preparing food, banking, following prescription instructions, driving or accessing transportation?
It is also necessary to assess the patient’s level of health literacy (University of New England, 2019). This entails assessing the patient’s ability to understand the concepts of managing their health and implementing a care plan. Studies have shown that higher levels of health literacy are associated with better overall health. The New Vital Sign (NVS) has been shown as an effective way to quickly assess a patient’s basic literacy and comprehension skills related to health (Cornett, 2009). It only takes 3 minutes to administer and should be included in a comprehensive health assessment.
Response to key questions. For the purpose of this paper, it is not necessary to go into the patient’s responses in detail. A quick overview of her answers to the interview questions will provide a snapshot of the way that social and environmental factors contribute to her health status. The patient maintains an active lifestyle. She drives and engages in numerous social activities within the community. She has a supportive family life, living with her daughter and son-in-law in an upscale suburban neighborhood in Connecticut. The answers to the questions will be useful in formulating her plan of care because they reveal the resources available to help the patient maintain her health as she ages.
As previously noted, economic stability is an important determinant of health. It allows for an individual to meet their basic needs for food, shelter, housing, and healthcare, which correlates to a reduction in health conditions associated with poverty and lack of access to medical care and medications. The patient’s response to questions related to economic stability indicates that she is in a stable economic situation and all of her basic needs are met.
The patient has a steady income from social security that covers her basic needs as well as significant savings as a result of paying into a retirement fund while she was working. As noted, she is retired. However, her unemployed status does not present a barrier to her economic stability. In addition, the patient lives with her daughter and son-in-law, who are upper-middle-class homeowners. As a result, her housing situation is stable.
The patient finished high school which has been a positive determinant of her health. Studies have shown that completing high school and attaining higher degrees of education improves an individual’s health outcome (Conti, Heckman, & Urzua, 2010). A solid educational background provided the framework for an economically stable life that allowed the patient to maintain her health.
After working in retail for a while she opened her own business – a convenience store. Her business allowed her to maintain a sense of economic stability throughout her life, which also made it possible for her to receive necessary and routine medical care consistently over the years. The patient’s level of education has a positive impact on her health and well-being by giving her a high level of health literacy. Her education and her status as a small business owner created opportunities that allowed the patient to live a healthy lifestyle and receive quality healthcare. She faces few barriers to healthcare thanks to her education and years as a business owner.
Advanced education is highly valued in contemporary America and many people believe that it is necessary to ensure economic stability and the skills necessary to navigate everyday life. However, in previous generations, it was possible to have a prosperous life with only high school education. Thought the patient did not attend college, she was able to open her own successful business and save money for retirement. As a result, her educational status does not present a barrier to healthcare. Indeed, since the patient was able to finish high school and start her own business, she created life-long economic stability which is actually created a healthcare opportunity. Her stability has meant that she never put off seeking necessary healthcare because she didn’t have enough money.
The patient is in good overall health, which allows her to lead an active lifestyle and enjoy a high quality of life. She is capable of living independently and still drives, which allows her to maintain a social life outside her immediate family. She has Medicare and is receives yearly checkups and utilizes health resources when necessary without facing any barriers due to lack of money or health insurance.
The patient’s medical history is what one would expect from a 70-year-old woman. She is at a healthy weight for her age and height 5’2” and weighs 125 lbs. She has a history of high cholesterol and osteoarthritis. Her high-cholesterol is treated with Simvastatin 20 mg daily. She also takes several dietary supplements, including fish oil, vitamin C, vitamin D and a multi-vitamin designed for elderly women.
The patient has had several medical procedures. She had a knee replacement surgery in May 2018 due to osteoarthritis. There were no complications with the surgery. She had surgery to repair her right meniscus repair 8 years ago. She also had shock wave lithotripsy to treat kidney stones. She also had basal cell carcinoma of the philtrum surgically removed. The patient receives routine yearly checkups as well as yearly follow-up exams with her dermatologist and urologist.
The patient has a good understanding of her health status and overall health literacy. Health literacy is an important determinant of health, especially in elderly patients. Health literacy is defined as an individual’s ability to “obtain, process and understand” health-related information and services that are necessary to make informed decisions about their health (Bostock & Steptoe, 2012). There are varying degrees of health literacy: basic functional health literacy, which refers to a patients ability to understand general health-related concepts; communicative interactive health literacy, which is a more advanced understanding of health-related concepts that allow the patient to communicate more effectively with their doctors; and critical health literacy, which refers to higher level cognitive processing of health information that allows for the most informed decision-making (Sykes, Wills, Rowlands & Popple, 2013).
Insufficient health literacy has been recognized as a social determinant of health and exacerbates health disparities for groups from low socioeconomic backgrounds, racial and ethnic minorities and people with chronic health conditions (Chinn & McCarthy, 2013). Poor understanding of information related to healthcare is related to increased mortality among elderly patients (Bostock & Steptoe, 2012). Individuals with limited health literacy fail to fully understand the information communicated to them by their healthcare providers, including explanations of their health conditions, lifestyle factors that contribute to the condition, health practices to improve the condition and directions for taking prescribed medications and treatment.
The patient lives in an environment that promotes health and well-being. She lives in an upscale neighborhood. Her daughter (who is a nurse) and son-in-law built an extension onto their house where the patient lives. She has nearby access to healthy food and healthcare services. Since the patient drives, she does not suffer from a lack of access to transportation.
Healthcare received in low and high-income areas. Studies have shown that people living in high-income areas have greater access to quality and affordable healthcare than those who live in low-income areas. In low-income neighborhoods, there is typically a large distance between healthcare facilities and pharmacies are a small number of healthcare centers are expected to meet the needs of a large number of people. These factors make it difficult to access care due to distance when reliable transportation is a problem. In addition, people living in low-income areas are often forced to wait longer to receive treatment due to the scarcity of resources. Since the patient lives in an affluent community and has her own car, she is not hindered by these barriers.
States have begun to work to overcome the different access to healthcare based on an area's income and there are some similarities between low- and high-income areas. For instance, the Affordable Care Act has expanded access to healthcare for both low- and high-income areas by expanding health insurance coverage (Schoen et al., 2013). Another similarity between low and high-income areas is that patients’ privacy is protected by physicians' ethics and federal law in both areas (Schoen et al., 2013).
Access to healthcare in rural vs. urban areas. Studies have shown that people who live in rural areas have less access to quality, affordable healthcare than people living in urban areas (Buzza et al., 2011). There are fewer healthcare facilities and services in rural areas, and the distance between them is greater. This means that patients without reliable transportation do not have easy access to necessary care. Since the patient lives in an urban area and has reliable transportation, she does not face a geographic barrier to accessing healthcare.
Availability of healthy food in the neighborhood. Access to fresh and healthy food in a neighborhood is an environmental determinant of health. People are more likely to make healthy eating options when they can purchase fresh fruit near where they live (Walker, Keane, & Burke, 2010). People who live in food desserts – neighborhoods without grocery stores – leave residents to travel great distances to buy groceries. As a result, people are more likely to eat fast food or junk food which is more easily accessible. Lack of access to grocery stores in some neighborhoods is associated with a disparity of health based on race/ethnicity and socioeconomic status (Walker et al., 2010). This environmental determinant of health does not affect the patient because she lives in a neighborhood with several grocery stores and has reliable transportation.
Numerous studies have shown that a comprehensive health assessment must include an examination of the social determinants of health that impact the patient (AHRQ, 2013). The major social determinants include economic stability, housing safety and stability, food security and a supportive family and community environment.
Lack of economic stability can leave patients without enough money to access health care and medication they need. Insufficient money can lead to food insecurity and a poor diet as an individual has to decide between spending money on electricity or other bills or food (Walker et al., 2010). Economic instability also means that an individual will likely not receive all of the necessary preventative care and treatment for illnesses and injuries they need because they cannot afford to pay the co-pay or deductible, or do not have any health insurance at all. Economic instability can have a negative net impact on health (AHRQ, 2013).
A lack of stable and safe housing has been associated with negative overall health outcomes. Unsafe housing conditions such as rodents, cockroaches and toxic mold can have a direct negative impact on an individual’s health (Buzza et al., 2011). Residing in an unsafe neighborhood also can be detrimental to health if residents are exposed to harmful air or water conditions, or if criminal activity jeopardizes their safety (Sowa et al., 2016). Seniors who have safe and stable housing typically have a higher quality of life and better health outcomes than those without.
Education is also an important determinant of health; the higher the level of education obtained, the more positive an individual’s health outcome (Cornet, 2009: Conti et al., 2010).). Having a high level of education makes it more likely that a patient will understand and follow doctors’ advice and adhere to medication regimens (Sykes et al., 2013).
While people with a college degree are likely to have a higher degree of health literacy than those without, studies have shown that graduating high school does correlate with a large degree of health literacy. In one study, 53% of high school graduates had intermediate health literacy, meaning they could read and understand medical directives and prescriptions (HHS, 2003). That was more than double the 23% of people who do not have a high school diploma. An additional 29% of high school graduates had basic health literacy, and 3% were proficient (HHS, 2003).
The three most significant social determinants of health that are likely to affect this patient are economic security, housing stability, and education. Her economic stability and housing security are assets. Due to her socio-economic status (upper middle class), the upscale neighborhood where she lives with her daughter and son-in-law (who own their home), and the support she has from her family and community, the patient is not negatively affected by social determinants of health. In this case, the determinants are opportunities for the patient’s health.
While some might consider the patient’s limited educational attainment as a barrier, it is actually not. As previously noted, the patient received her high school diploma at a time when that level of education was sufficient to start a business. The patient’s business was successful and provided her with the economic stability over the course of her life to ensure that she did not put off necessary medical care.
In addition, a high school education is sufficient to provide the patient with the literacy skills necessary to be able to read and understand medical directions, as well as to understand verbal communications from her healthcare providers, which are necessary elements of health literacy (Sykes et al., 2013). Therefore, the fact that she finished high school means that her educational as a determinant of health was, in this case, one of opportunity.
The social determinants of health have a positive impact on the health and wellbeing of the patient. Her economic stability has ensured a lifetime of access to healthcare and a history of consistently having her basic needs met. Her environment is safe and free of crime, which has a positive impact on health. She has easy access to healthcare facilities and healthy foods. She has a supportive social circle that also has a positive impact on her overall health.
As the above discussion has shown, the social determinants of health that typically function as barriers to seniors’ healthcare are not barriers in this patient’s case. The plan of care does not need to overcome barriers with housing stability, socioeconomic status or education. Rather, it should tap into the assets (economic and housing stability, and educational level) to formulate a plan of care that will ensure the patient receives quality care as she continues to age.
While the patient is very active now and is able to enjoy a great deal of independence despite her history of knee problems, a plan of care must be in place to ensure that the patient gets the care and support she needs as she continues to age, and her health deteriorates as a consequence. The three social determinants of health that most impact the patient include: her neighborhood, her family support, and her economic stability.
As a part of the nursing plan of care, these resources should be tapped into to ensure that the patient continues to receive her regular checkups and follow-ups with specialists. For instance, support from her family and community will help the patient get to her appointments when she is no longer capable of driving herself. The plan of care should include incorporating the patient’s daughter into planning for the patient’s future medical issues with the patient’s primary care doctor and specialists.
The plan will be implemented in the coming years as the patient ages and begins to need more assistance from her family. The major barrier to the plan implementation is that the daughter works full time as a nurse and has other responsibilities that take up her time. In order to overcome this barrier, the patient and her daughter will need to enlist other family members to share the responsibility.
Since the plan of care consists of creating a strategy to ensure that the patient continues to access healthcare services as she ages, evaluating its effectiveness will not be possible until it is actually put into action. Evaluation will require determining whether the plan of care achieved its primary goal of providing the patient with the necessary support to make it to her routine and follow-up appointments.
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