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As a care coordinator in a local hospital, you have been asked to meet with a 90-year-old female patient who was recently admitted to the hospital with shortness of breath and frequent falls. During your initial visit with the patient, you meet her 50-year-old daughter. There is a significant language barrier with both the patient and the daughter, as well as low health literacy. There does not appear to be any additional family to contact. You have been able to determine they are from South America and have been in the United States for less than a year. They are currently homeless, with no source of income, and living in a rural area with minimal resources.

You are tasked with maintaining a therapeutic alliance and getting your client the services she needs.
A. Discuss the patient’s immediate needs and referrals for services in preparation for discharge.

B. Describe how the patient’s understanding of her medical condition and her available options to care will be assessed.

C. Explain how the patient’s location, background, and life circumstances will affect outcomes.

D. Describe methods that you could use to understand this family’s communication style and culture better to enhance your professional relationship.

E. Describe the effect social determinants of health have on this patient’s health by doing the following:

1. Identify the barriers this patient faces related to social determinants of health.

2. Identify the gaps between clinical care for the patient and community resources.

F. Explain strategies to engage community relationships with stakeholders to support the patient in the scenario.

G. Analyze two national standards of Culturally and Linguistically Appropriate Services (CLAS) applicable to the patient’s health disparities in the scenario.

H. Recommend an evidence-based intervention that includes the following:

• Community involvement

• Cultural considerations

• Improves an identified health disparity.

I. Describe community resources to support patient adherence to potential lifestyle changes after discharge, with consideration of the patient’s cultural norms.

J. Discuss information that could be provided to the hospital that would decrease the cultural misunderstandings regarding the immigrant population and help the hospital understand the needs of this population.

1. Describe the community resources that might be accessed to support and sustain the hospital’s cultural intelligence development.

2. Describe two accreditation standards, laws, professional standards, or funding requirements that relate to cultural intelligence.

K. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

L. Demonstrate professional communication in the content and presentation of your submission.


Discharge Planning

Student’s Name
Institutional Affiliation
Course Name and Number
Instructor’s Name

Discharge Planning
In order for a patient to be successful, healthy, and recuperate from their illness, discharge planning and service are essential. It ensures that all impediments are noted and solutions and possibilities are discovered. The process of planning enables the team to collaborate with the patient and their family to build a successful strategy for the patient.
The patient’s immediate needs and referrals
She is a 90-year-old woman who is homeless, has no money, is an immigrant, and lives in the rural region. She has minimal health literacy. Many things are important to her, yet certain things are more important than others for her. Basic wants such as food, shelter, and clothes are the most essential, according to Maslow’s Hierarchy of Requirements. Once these needs are addressed, all other needs can be fulfilled (Narvaez, 2018). A continuous place to sleep, whether it’s in a shelter or a low-income housing or community-based housing initiative, is essential to her current situation. As a result of the language barrier, a translator is an absolute need for both her and the hospital in order for everything to go as smoothly as possible. This patient will be sent to social services for assistance in obtaining medical insurance, snap compensation, and SSI if feasible. Since she is from South American descent, t would be important to get in touch with people from that region who could be able to provide a hand in her time of need. These people may also be able to provide information on locations where you may her find a place to stay. Most Federally Qualified Health Centers (FQHCs) are located in rural regions and are fluent in Spanish and other languages.
Patient’s understanding of her medical conditions
In order to have a positive health result, the patient must fully comprehend her pharmaceutical regimen. In the event that a patient does not grasp the need of taking their prescription on time, it might lead to serious consequences for them. So a translator will be hired to convey the illness to the patient in simple words, so that medical jargon is avoided. Using visual aids, such as posters and handouts, to educate the patient about their disease and allow them to teach back. While discussing what would perform effectively for the client and her daughter’s lifestyles, reiterating the possibilities that are accessible to the client in their own terms would enhance the patient’s understanding of her medical conditions, and need for care.
How location, background and life circumstances will affect outcome
The patient’s health result might be affected by a variety of circumstances. Location, ancestry, and the course of one’s own life are only a few examples. Rural living limits the patient’s access to medical treatment, as well as the providers she may choose from and the resources she can use for assistance. She is presently living in a remote place that lacks resources and assistance for her health improvement. As a South American immigrant, the patient has a language barrier as well as a lack of knowledge about health care. Having just arrived in the United States a short time ago, the client does not yet have the community connections or financial means necessary to succeed.
Professional relationship enhancement
During an interview, open-ended questions enable the client to provide as much information as they think is necessary for their treatment (Pun et al., 2018). For a good health result, it is important to know how the client perceives healthcare and how they have earlier sought treatment in South America as well as customs, religion, beliefs, and any other nuances essential to know about how their culture handles diseases. This assessment interview should also be conducted in her original language, whether that means hiring a translator in Portuguese or Spanish or any other language she can speak. My next step would be to seek out groups that support South American immigrants or organizations that also communicate in her native language to learn more about her culture, values, and customs. This would help me build a connection with the client and help me better serve her.
A lack of flexibility, a lack of access to treatment in a remote region, and a lack of resources to satisfy daily requirements by way of housing and no income are all examples of socioeconomic health determinants in the scenario.
Income, the capacity to pay for prescriptions and food, health insurance, transportation to and from treatment, and language assistance are some of the gaps between healthcare delivery for the patient and cultural influences. If a patient only goes to the doctor when he or she is unwell, there is a huge cultural difference in the way healthcare is seen.
Community relationships engagement with stakeholders
Working with community partners to offer translators and staff training in cultural, linguistic, and ethnic competency is one way to engage community ties with stakeholders. Initiating a connection with an area volunteer organization, which may be able to help with things like food and pantry supplies, clothes, and transportation, is another way to become involved. Thirdly, using the United Way resources for local agency recommendations, such as housing and social assistance organizations that may help meet the client’s fundamental requirements. Ensure that the connection with resources is mutually beneficial and a win-win situation. The win-win method helps to make the collaboration workable for all parties concerned. Additionally, the hospital might buy neighborhood clinics or medical practices medical centers or create a portable clinic in remote areas to make healthcare more accessible.
Two national Standards of CLAS applicable
For this situation, the first CLAS standard that may be implemented is standard five: “providing language help to those who have low English proficiency and/or other communication requirements, at no cost to promote immediate access to all medical services (Delphin-Rittmon et al., 2021).” This may be done by offering language services and instructional resources that are in the chosen language of the customer. The second standard is the sixth which entails notifying all persons of the availability of language assistance programs clearly and in their chosen language, orally and in writing need may be met by putting up signs promoting the availability of translation and language services, as well as by providing such services and documents in many languages.
Evidence-Based Intervention
Reduce readmissions with the help of a patient navigator, PARTNER. This is similar to the function of a care coordinator. For the first 30 days following release, this includes calls and home appointments to check that all of the patient’s requirements are being fulfilled. Partner is designed for people with poor reading levels and who have trouble controlling their healthcare. The navigator is in charge of coordinating the minority’s healthcare and will go out of their way to locate community resources and assistance in order to help the group maintain good health.
Community resources to support patient’s adherence to lifestyle changes
Community education on a disease promotes mutual knowledge of it and its implications, and necessary care (Tam, Wong, & Cheung, 2020). Educating the community about the woman’s illness with enhance her understanding and hence promote her adherence to lifestyle changes. Organizations representing specific diseases in a community are a vital community resource as they act as advocates for patients, promoting lifestyle changes adherence. Also, prioritizing the patient’s needs will ensure she has many people making her accountable for her illness.
Information provided to the hospital to decrease cultural misunderstandings
Some of the information that could be provided to the healthcare facility to reduce cultural barriers are the patient’s cultural, religious and spiritual beliefs (Sanchez-Polo et al., 2019). This knowledge would enlighten healthcare providers on how to deliver care to patients from such culture by promoting respect for the cultural differences, hence proper interaction with patients.
Community resources to support the hospital’s cultural intelligence development
Translation organizations in the community would enhance the hospital’s cultural competence by enabling it to provide care even to patients of different ethnic communities (Luquis, 2021). Also, organizations that financially support minority groups in the community would help minors access healthcare.
Accreditation Standards that relate to cultural intelligence
Laws that govern cultural competence include value for diversity. For an institution to be culturally intelligent, its operationability should value differences among different cultures. It should also value the dynamics employed in cultural interactions, have institutionalized cultural understanding, have a capacity to assess itself culturally, and adapt delivering services with an understanding of cultural diversity (Ishakova & Ott, 2020).

Delphin-Rittmon, M. E., Boynton, E. S., Ortiz, J., Davidson, L., & Flanagan, E. H. (2021). The Organizational Multicultural Competence Assessment (OMCA): A tool to assess an organization’s multicultural competence and adherence to the National Standards for Culturally and Linguistically Appropriate Services in Health and Healthcare (the National CLAS Standards). Psychiatric Rehabilitation Journal, 44(2), 99.
Iskhakova, M., & Ott, D. L. (2020). Working in culturally diverse teams: Team-level cultural intelligence (CQ) development and team performance. Journal of International Education in Business.
Luquis, R. R. (2021). Integrating the concept of cultural intelligence into health education and health promotion. Health Education Journal, 80(7), 833-843.
Narvaez, D. (Ed.). (2018). Basic needs, wellbeing and morality: Fulfilling human potential. Springer.
Pun, J. K., Chan, E. A., Wang, S., & Slade, D. (2018). Health professional-patient communication practices in East Asia: An integrative review of an emerging field of research and practice in Hong Kong, South Korea, Japan, Taiwan, and Mainland China. Patient education and counseling, 101(7), 1193-1206.
Sánchez-Polo, M. T., Cegarra-Navarro, J. G., Cillo, V., & Wensley, A. (2019). Overcoming knowledge barriers to health care through continuous learning. Journal of Knowledge Management.
Tam, H. L., Wong, E. M. L., & Cheung, K. (2020). Effectiveness of educational interventions on adherence to lifestyle modifications among hypertensive patients: an integrative review. International journal of environmental research and public health, 17(7), 2513.


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