NRS397: Discharge Plan for Patient Case Study Essay Assessment

Assessment Item 2

This assessment task requires you to examine the care and management of a person living with a chronic condition after discharge from hospital after an acute exacerbation. You get the ONE case study and then you use it for both Assessment 1 + Assessment 2. You are continuing from Assessment 1 and using the SAME case study. The case study you have used in the first assessment task will provide the basis for your discussion.

You are required to read the case study carefully and write an essay addressing the following points:

• Discuss the implications of the person’s comorbid diagnoses in the scenario on their everyday life and requirements for ongoing management;
• Discuss person-centred discharge planning to optimise quality of life through selfcare and autonomous decision-making, relevant to the person in the scenario;
• Identify two relevant interdisciplinary team members and describe their contribution to providing ongoing support for the long-term management of the person’s condition;
• Discuss The National Strategic Framework for Chronic Conditions and consider how it could be used to support optimal management for the person in the scenario. Here is the link Australian Health Ministers’ Advisory Council, (2017), National Strategic Framework for Chronic Conditions. Australian Government. Canberra.

Ensure that you integrate information and examples from the case study to demonstrate the depth of your knowledge. This assessment item must be presented as a scholarly paper and include an introduction, conclusion, supporting research evidence, and a reference list. It is strongly recommended that headings are used to organise the paper. Tables and dot points are not accepted.

Summary of Assessment Requirements

The assessment required students to examine the ongoing care and management of a patient living with a chronic condition following discharge from the hospital after an acute exacerbation. Using the same case study from Assessment 1, students were expected to demonstrate their understanding of post-discharge care planning, interdisciplinary collaboration, and the application of national health frameworks to promote patient well-being and autonomy.

Key components to be addressed included:

1. Implications of Comorbid Diagnoses: Discussion on how the patient’s multiple health conditions impact daily life, treatment needs, and overall health management.

2. Person-Centred Discharge Planning: Strategies to optimise the patient’s quality of life through self-care, empowerment, and shared decision-making.

3. Interdisciplinary Team Collaboration: Identification of at least two key healthcare professionals involved in the long-term care process, outlining their roles and contributions.

4. National Strategic Framework for Chronic Conditions (NSFCC): Application of its principles to support evidence-based, holistic management for the patient.

The essay was to be written in a scholarly format, featuring an introduction, body with logically organised headings, and a conclusion, supported by current research evidence and proper referencing.

Step-by-Step Approach by the Academic Mentor

The Academic Mentor guided the student through a structured and evidence-based process to help them meet each assessment criterion effectively:

Step 1: Understanding the Case Study Context

The mentor began by revisiting the Assessment 1 case study, ensuring the student fully understood the patient’s chronic condition, recent hospitalization, and ongoing care needs. The mentor emphasized identifying the key chronic conditions and associated comorbidities that would influence the patient’s recovery and daily life.

Step 2: Analysing Comorbid Diagnoses

The mentor encouraged the student to explore how the coexistence of chronic conditions affects physiological, psychological, and social aspects of the patient’s life. Academic sources and clinical guidelines were used to strengthen the analysis, linking comorbidities to potential barriers in self-care and long-term management.

Step 3: Developing the Person-Centred Discharge Plan

The mentor guided the student to frame the discharge plan using person-centred principles focusing on the patient’s preferences, goals, and self-management capacity. The student was supported in aligning the discharge strategy with patient empowerment and autonomy while considering home care support, medication adherence, and lifestyle modifications.

Step 4: Incorporating Interdisciplinary Collaboration

The student was directed to identify two essential healthcare professionals for instance, a chronic care nurse and a physiotherapist and elaborate on their specific roles in continuity of care. The mentor reinforced the importance of interprofessional communication, care coordination, and patient education in preventing readmission and promoting long-term stability.

Step 5: Integrating the National Strategic Framework for Chronic Conditions (NSFCC)

The mentor provided guidance on interpreting the NSFCC (2017) and demonstrating its application in care planning. The student was shown how to connect framework priorities prevention, early intervention, and integrated care to the case scenario to demonstrate a strong policy-to-practice link.

Step 6: Structuring the Scholarly Essay

Finally, the mentor reviewed the essay outline, ensuring a logical flow from introduction to conclusion. Emphasis was placed on academic writing conventions, critical analysis, and evidence-based discussion using recent peer-reviewed sources. The mentor also helped refine transitions, referencing, and coherence for a polished final submission.

Outcome and Learning Achievements

By the end of the mentoring process, the student successfully:

• Demonstrated a comprehensive understanding of chronic disease management in post-discharge contexts.
• Applied person-centred care principles to real-world clinical decision-making.
• Showcased the ability to integrate interdisciplinary collaboration in long-term patient management.
• Linked theory and policy through the practical application of the National Strategic Framework for Chronic Conditions.
• Produced a well-structured, evidence-based scholarly paper that met academic standards and assessment criteria.

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