Eleven People and One Four-Year-Old: Interprofessional Collaboration in Home Care for a Child With a Tracheostomy
Student Name
RN to BSN Program, Aspen University
N493: Community Health II
Instructor Name
Month Day, Year
Eleven People and One Four-Year-Old: Interprofessional Collaboration in Home Care for a Child With a Tracheostomy
Home care moves complex treatment out of the hospital and into family homes, and with it moves the work of coordinating many professionals who rarely meet. Children with medical complexity show that challenge most clearly. They have multiple chronic conditions, depend on technology such as tracheostomies and feeding tubes, see many specialists, and use a large share of pediatric health care services (Cohen et al., 2011). This paper describes a composite child receiving care at home, identifies the members of her interprofessional team and their roles, examines what the evidence says about collaboration, and proposes how a home care nurse can coordinate the team.
The Child and Her Family
M. is a composite 4-year-old girl born at 25 weeks' gestation who developed severe bronchopulmonary dysplasia. She has a tracheostomy and uses a home ventilator at night, receives most of her nutrition through a gastrostomy tube, and has developmental delays in speech and motor skills. She lives with her parents and her 7-year-old brother in a rented house 40 minutes from the children's hospital. Her mother left her job to care for her; her father works days at a manufacturing plant. Private duty nurses cover some night shifts, but the agency has been unable to fill about a third of scheduled hours, so her parents often stay awake to watch her breathing.
In the past year M. was hospitalized three times, twice for respiratory infections and once when her tracheostomy tube became dislodged and a parent had trouble reinserting the replacement. Her family describes the hardest part of her care not as any single task but as keeping track of who is responsible for what.
The Interprofessional Team
At least eleven people or services are involved in M.'s care. Her pediatrician is her medical home; a pulmonologist manages the ventilator and tracheostomy, and a gastroenterologist oversees feeding. A home health registered nurse visits weekly for assessment and teaching, and private duty nurses provide overnight care. A respiratory therapist from the durable medical equipment company maintains the ventilator and suction equipment. A dietitian manages her formula and growth. Physical, occupational, and speech therapists deliver early intervention services at home. A social worker at the hospital helps with insurance and respite resources, and her future preschool teacher will join the team this year. Her parents, who perform most of her daily care, are the most important members of all.
Each professional brings expertise the others lack. The problem is that they work from different records, on different schedules, and often communicate only through the parents. When the pulmonologist changed M.'s ventilator settings after her last admission, the home health nurse learned of it from her mother a week later, and the private duty nurses had not been told.
What the Evidence Says About Collaboration
The American Academy of Pediatrics has described the management of children with medical complexity as a task for the medical home working with a medical neighborhood of specialists and community services, with goals that include fewer unplanned hospital admissions and emergency visits, better access to services, lower out-of-pocket costs for families, and better family experience and quality of life (Kuo et al., 2016). Care coordination and a shared care plan are central to that approach.
The broader evidence on interprofessional collaboration is encouraging but limited. A Cochrane review of practice-based interventions to improve interprofessional collaboration, such as team meetings, interprofessional rounds, and checklists, included nine randomized trials and found that some interventions may slightly improve patient functional status and adherence to recommended practice, but that the certainty of the evidence was low and the effects on many outcomes were uncertain (Reeves et al., 2017). The honest conclusion is that collaboration is necessary for children like M., but the specific tools that make it work still need testing, which is a reason to build evaluation into any coordination effort.
The Home Care Nurse as Coordinator
The home health nurse is well placed to coordinate M.'s team because she sees the child in her home every week, knows the parents' routines and worries, and speaks the clinical language of every other member. A practical coordination plan has four parts.
First, a single shared care plan. The nurse drafts a one-page summary with M.'s diagnoses, current ventilator settings, tracheostomy tube size and emergency replacement steps, feeding regimen, medications, and a contact list, and updates it after every change. The plan is kept in a binder at home, sent to every team member, and brought to every appointment. Second, a regular team conference. The nurse arranges a monthly 30-minute video call with the parents, the pediatrician's care coordinator, the respiratory therapist, the private duty agency supervisor, and the therapists, with specialists joining when changes are planned. Third, clear communication rules. Any change in settings, medications, or feeds is sent to the nurse and the private duty agency on the same day, and the nurse confirms that the shared plan has been updated.
Fourth, attention to the family's capacity. The nurse reviews emergency tracheostomy replacement with both parents until each can perform it confidently, since that skill failed during a past admission, and works with the social worker to pursue respite care and advocate with the private duty agency and the insurer about unfilled nursing hours. Coordination that ignores the parents' exhaustion will fail no matter how well the professionals communicate.
Evaluating the Plan
Because the evidence for specific collaboration tools is limited, the team should track whether its approach is working. Useful measures include unplanned hospital admissions and emergency visits over the next year compared with the previous year, the percentage of care changes that appear in the shared plan within 48 hours, the percentage of scheduled private duty hours actually filled, and the parents' own rating of whether they know who is responsible for each part of M.'s care. The last measure matters most, since it answers the problem the family named at the start.
Conclusion
Home care for a child with medical complexity is a team effort that happens in a family's living room rather than a hospital unit. The professionals involved each bring essential skills, but without deliberate coordination the family becomes the only link among them, and important information falls through the gaps. A home care nurse can close those gaps with a shared care plan, regular team conferences, clear communication rules, and support for the parents who carry most of the care. The evidence on collaboration is still developing, so evaluating the team's own results is part of doing the work well.
References
Cohen, E., Kuo, D. Z., Agrawal, R., Berry, J. G., Bhagat, S. K. M., Simon, T. D., & Srivastava, R. (2011). Children with medical complexity: An emerging population for clinical and research initiatives. Pediatrics, 127(3), 529-538. https://doi.org/10.1542/peds.2010-0910
Kuo, D. Z., Houtrow, A. J., & Council on Children With Disabilities. (2016). Recognition and management of medical complexity. Pediatrics, 138(6), Article e20163021. https://doi.org/10.1542/peds.2016-3021
Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6), Article CD000072. https://doi.org/10.1002/14651858.CD000072.pub3
How this N 493 Module 7 example is structured
N493's catalog description names community-based home care and collaboration with the interdisciplinary team, and in many sections a later module asks for a paper on home care, the team involved and the nurse's role. Aspen does not publish module deliverables, so check your classroom for the exact prompt. This example chooses a case where coordination is visibly hard, lists every team member and role, reads the evidence honestly, builds a coordination plan from the problems in the case and closes with measures that include the family's own view.
N493 Module 7 questions, answered
What does N493 Module 7 usually ask for?
N493 covers community-based home care and collaboration with the interdisciplinary team, and a late module commonly asks for a paper on home care for a specific patient or population, the roles of team members and how the community health nurse coordinates care. Aspen does not publish module deliverables, so your classroom's instructions govern.
How should I describe the interprofessional team?
Name each member or service, state what each contributes, include the patient and family as team members, and then show where communication breaks down. The sample lists eleven people and services and uses a missed ventilator change to show the coordination gap.
What if the evidence for my intervention is weak?
Say so and plan to evaluate. The sample reports that a Cochrane review found low-certainty evidence for collaboration interventions and responds by building measurable outcomes into the coordination plan, which is stronger than overstating the evidence.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Aspen University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.