NR 601 Week 1 Collaboration Cafe

3. Recommended Plan of Care & Rationale A. Immediate Priorities: Safety, Dialysis, and Basic Needs First, I would address the most time-sensitive and life-sustaining needs: 1. Dialysis Adherence & Transportation o Collaborate with the dialysis center social worker and case management to arrange consistent transportation (e.g., Medicaid-funded non-emergent medical transport, paratransit, or community/tribal transport services). o Ask the dialysis team if they are aware of any patterns of missed treatments and co-develop a plan with Alice to prevent future gaps. o Explore appointment times that best match her energy and transportation availability. 2. Food Insecurity and Nutrition o Screen formally for food insecurity (e.g., “In the last 12 months, did you ever worry that your food would run out before you had money to buy more?”). o Refer to social work for enrollment or optimization of SNAP, local food pantries, Meals on Wheels, or renal-friendly food delivery programs. o Involve a renal dietitian to help her navigate a kidney- and diabetes-friendly diet that fits both her budget and cultural preferences. 3. Depression and Emotional Distress o Screen with PHQ-9 and assess for suicidal ideation or hopelessness. o Offer referral to behavioral health (counselor or psychologist, ideally with experience working with Indigenous patients), and consider starting antidepressant therapy if appropriate, using kidney-safe options and careful monitoring. o Validate her feelings: let her know that many people in her situation feel overwhelmed and that there is support. B. Medication Review & Polypharmacy Management I would perform a comprehensive medication reconciliation with attention to: • Renal dosing and potential nephrotoxicity (e.g., avoiding NSAIDs, adjusting doses). • Medications with limited benefit at her age/stage (e.g., very aggressive glycemic or lipid targets may not be appropriate). • Duplications and unnecessary PRNs. • Pill burden and cost—switching to generics, once-daily formulations, or combination pills when appropriate. Working with a pharmacist, I would create a deprescribing plan, prioritizing medications with the lowest benefit-to-harm ratio and highest risk (e.g., sedatives, strong anticholinergics, overly tight diabetes meds in the setting of food insecurity). I’d also explore medication synchronization, blister packs/pill organizers, and 90-day supplies to simplify her life. o “Are there cultural or spiritual practices that are important to you in how you manage your health?” o “Have you ever had any experiences with the health care system that made it difficult to trust providers?” • Invite traditional healing if desired: o Ask if she uses traditional medicines or healers and explore ways to safely integrate them with her biomedical treatments instead of dismissing them. • Use shared decision-making grounded in her values: o Frame decisions (like deprescribing, dialysis goals, or advance care planning) in terms of what she wants for herself and her community, not just disease guidelines. • Leverage Indigenous and community resources: o Connect her to Indigenous-serving health programs, community centers, or tribal resources when available. • Use trauma-informed principles: o Approach interactions with respect, transparency, and an awareness that her mistrust or hesitancy may be shaped by more than just individual experiences. By doing this,