Visit 3

Social/Emotional/Spiritual Status and Closure

Objectives:

1. Demonstrate interprofessional professionalism in interactions with assigned patient and team.
2. Establish, re-establish, and maintain rapport with assigned patient and team.
3. Update V/S and meds; describe changes at Visit 3.
4. Assess and categorize health risk factors/level:
   • Two Question Depression Screen
   • Duke Social Support Scale or Holmes-Rahe Social Readjustment Scale (HR SRS)
   • HOPE spiritual assessment
5. Discuss stress/life change with the patient and how that impacts health.
6. Share USPSTF recommendations with patient (in patient appropriate form)
7. Collaborate with patient to identify positive health behaviors--prevention, maintenance, and areas for improvement.
8. Create a wellness plan WITH the patient.
9. Closure.

Activities:

1. Review materials and guide; work with team to prepare for Visit 3.
2. In preparation for Visit 3, look up age/gender-specific USPSTF recommendations for at least one of your patient's health issues. Once on the site, use "search" to find recommendations for "adult, Senior." http://www.uspreventiveservicestaskforce.org/Page/Name/recommendations
3. Assemble and prepare to share any additional education resources identified for your patient.
4. Complete Visit 3 with elder.
5. As a team, prepare a patient presentation for the review session.

Guide for Visit 3:

1. Re-establish rapport with team and patient.
2. Update health history with any changes since last visit; include current medications and the reason they're prescribed.
3. Assess patient vital signs/physical exam noting any changes.
4. Review last visit with your patient.
5. Ask about the impact of stress/difficulties (including perceived discrimination, if appropriate) on health and well-being.
6. With the patient, work through the:
   1. Two Question Depression Screen
   2. Duke Social Support Survey OR
   3. HOPE Spiritual Assessment
7. Share information on age/gender-specific USPSTF recommendations for at least one of your patient's health issues identified in Visit 1.
8. Ask patient about goals/plans to maximize his/her health and wellness.
   1. Use Brief Motivational Interviewing to identify goals/patient's unique resources/challenges
   2. Collaborate with patient to make Action Plan
   3. Review/Describe community resources available for maximizing health
9. Discuss with patient how team / team members (or health care providers in general) might improve their interactions with patients.
10. Thank your patient for being an integral part of your education.