Nursing practice: Outline the relevant care coordination skills you as the Registered Nurses require to effectively manage Liam’s shared care plan.

Written Assignment

Weight: 60%

Word Length: 2000 words

Notes: Written assignment

Liam is a 15-year-old male patient who has recently joined the program. You have not met Liam previously and he and his mother, Erica, are due to attend the surgery later today. In preparation for Liam’s appointment you review his patient’s notes and shared care plan. On review you note that the shared care plan has been started however is not yet complete. 


Review the attached case study of Liam and his shared care plan then answer the following questions:

Part one

Complete the missing information on Liam’s care plan and provide the relevant information;

  1. Patient Care Team: Identify all of the facilities, organisations and professionals Liam and his parents will have to access/interact with to achieve his treatment goals. Separate these into primary secondary or other (if relevant) and document the referral process and their role in Liams’ care.
  2. Patient’s barriers to care goals:  Review the patient care goals identified on the care plan. Identify barriers for achieving the care goals (note: may be: medical, situational system. Consider self-management strategies, health literacy and the team goals, this is not exhaustive).

Part two

Role of the RN as the complex care coordinator to deliver the shared Care Plan

  1. Nursing practice: Outline the relevant care coordination skills you as the Registered Nurses require to effectively manage Liam’s shared care plan.
  2. Identify Strategies: As the complex care coordinator you have to effectively implement Liam’s shared care plan. Identify any/all projects, programs, technology, organisations, innovations etc. that would assist with delivering the goals identified in Liam’s shared care plan.

HSNS363 Assessment 2 case study: Liam

Meet Liam


Liam is a 15-year-old male who lives in Westtown with his mother, Erica. Liam is a patient of Dr Jones and moved to the clinic when her practice merged with another local practice to form the Youbeaut clinic late last year. 

Liam has a history of Juvenile Idiopathic Arthritis (JIA) and Asthma. Liam attended the Accident and Emergency department at the Westtown Hospital four times last summer, including one overnight admission, due to acute exacerbation of Asthma. The Westtown region has been drought declared for the last two years and is experiencing large dust storms which triggered Liam condition. Liam fractured his right hand three years ago when he fell of his bike. 

In addition to his recent asthma exacerbations Liam has also been experiencing pain related to his JIA, particularly in his right wrist and right knee. Dr Jones has referred him for review with his regular paediatric rheumatologist in Sydney which is located 500km away. Liam is to have an MRI prior to attending the appointment. In light of his recent Asthma exacerbations Liam is also due to visit his regular paediatrician to review his Asthma Action Plan. His paediatrician is located in a rural service centre 250km from Westtown.


Medical History

  • JIA – diagnosed at the age of 8,  four joints involved
  • Asthma – diagnosed at the age of 10
  • Right carpel/scaphoid fracture 3 years ago (cycling accident).


  • NSAIDS – BD naproxen 250mg
  • Paracetamol PRN for pain.
  • Inhaled corticosteroid preventer (daily)
  • Salbutamol PRN


Liam lives with his mother Erica (37), step father John (39) step-brother Sam (7) and step-sister Molly (4). Liam has a god relationship with Erica, John and his younger siblings however, this is a busy household with both parents working and all children attending different school/childcare facilities. John is a supervisor at the local mine. He is a shift worker and his hours include evening and weekend work.  Erica works full time at the local bank.

Liam spends alternative weekends and half his school holidays with this father, Michael (45), his step mother Annie (44) and twin step-sisters Charlotte and Grace (18 months). Michael and Annie live on a mixed farming property 25km from Westtown. Annie and Michael tried unsuccessfully to have children for several years prior to the arrival of their daughters. Charlotte and grace are very welcome additions to the family however Michael and Annie are finding the demands of caring for two young children (largely unassisted) and running the farm incredibly tiring with little-to-no spare time.

Liam has a good relationship with his father and Annie however, when he is at the farm he feels as though there is a ‘burden’ and is largely left to himself due to the time and attention required to care for the twins and run the farm.

Michael and Erica often struggle to balance the responsibilities of transporting Liam the multiple medical appointments and therapy sessions including:

  • Monthly medical appointment in Sydney
  • Local fortnightly physiotherapy
  • GP appointments as required
  • Paedtrician appointment quarterly.  

Academic & Social

Liam enjoys school however, he is socially introverted and is sometimes bullied. He finds it difficult to complete school work when his hand is painful due to JIA particularly at the fracture site (Liam is right handed). Liam has one very close friend, Jack, who he has attended school with since kindergarten. Jacks and his parents recently relocated to Sydney for work.

Erica is concerned that Liam is becoming increasingly socially withdrawn. These days he mainly stays in his room and plays video games.  Erica is concerned that he is becoming depressed. She has to constantly remind him to take his medication (he was previously independent) feels like she is ‘nagging’ concerned about what is happening with his medication when he is at the farm.

Erica is hopeful that participating in the Healthcare Homes program will assist in better managing Liams’ care, particularly given his current physical and mental health status.

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