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Ch 9 Care Coordination
Terms in this set (54)
public health nursing (care)/ community health care
population based and focus on health of whole community
larger than community based
also known as community health care
community based care
health care provided to people who live within a defined geographic area
centers on individual and family heath care needs
role of nurse in community based care
Provide continuity of care when patient moves from one level of care to another or from one setting to another.
Provide interventions to promote health.
Manage acute or chronic illness.
Meet people's needs as they move between health care settings
Qualities of Community Based Nurse
Knowledgeable and skilled
Independent in making decisions
knowledgeable and skilled
effective communication and clinical skills
min 1 year of clinical practice
administer IV fluids, changing complex wound dressings, caring for ostomies, providing ventilator care
nurse is accountable to the patient, family and primary health care provider
roles of community based nursing
Patient advocate (to insurance, understanding bills)
Coordinator of services
Patient and family educator (increase self-care)
protection and support of another's rights
primary source of communication and coordination
responsible for coordinating community resources
continuity of care
primary responsibility of nurse
process by which health care providers give appropiate, uninterrupted care and facilitate patient's transition between different settings
ensures a smooth transition (b/w acute care and home health care)
Communication - prevent errors, gaps in treatment, oversight
help with transferring (from one unit to another or to a different facility)
accurate information about a patient's plan of care
approach to handoffs
provides framework for communication between members of the health care team about a patient's condition
situation, backround, assessment, recommendation
adds introduction(people involved in handoff) and questions and answer components
tips for effective handoffs
face to face
conduct at beside
A nurse is handing off a patient to a nurse in an extended-care facility using the ISBARQ framework of communication. Which step is performed correctly?
The nurse introduces the patient to the new nurse.
The nurse discusses the patient's background.
The nurse assesses the patient's vital signs.
The nurse questions the patient about comfort level.
B. The nurse discusses the patient's background.
Rationale: During ISBARQ, the nurse initiates introductions for the people involved in the handoff, explains the patient situation and background, gives the current provider's assessment of the situation, identifies pending lab results and what needs to be done over the next few hours, and provides an opportunity for questions and answers
continuous process in which a patient's care shifts from being provided in one setting of care to another
central responsibility of all health care professionals (nurses)
mechanism to make sure that patients get the right care at the right time in the most effective and cost-effective manner by the right person at the right setting
improve information exchange and reduce fragmentation and duplication of services
demands for care coordination
increasing numbers of older adults, increasing chronic illnesses, availability of costly medications and treatments
care provider (nurse) who is responsible for identifying a person's health goals and coordinating services and providers to meet those goals
self-management, patient advocacy
People with disabilities or multiple chronic conditions
People with mental illnesses or substance abuse
Cultural, racial and ethnic minorities
The rural and urban poor (poverty and homelessness)
Isolation results in not adequate health care (health illiterate)
ask ourselves about biases
Establishing an effective nurse-patient relationship
Reduce anxiety through therapeutic communication, teaching, and acceptance.
Remember that the patient has concerns and needs other than medical ones.
Communicate with the patient as an individual.
Take time to learn about the patient being admitted.
Provide for family participation in all aspects of care.
Tell whether the following statement is true or false.
In same-day surgery clinics, screening tests and teaching take place upon admission to the clinic.
Answer: B. False
Rationale: In same-day surgery clinics, screening tests and teaching take place prior to admission to the clinic
Admission to ambulatory care setting
Patient receives health care services but does not remain overnight.
In most offices and clinics, patients complete a short health history.
In same-day surgery facilities, screening tests, teaching, and admission take place before patients enter the setting.
ex- physician offices, clinics, outpatient services, emergency departments
Admission to a hospital
Admission sheet becomes part of the medical record.
Bracelet is placed on wrist of patient (ID number, name, birth date; safety)
A nursing interview and physical assessment are conducted.
A room is prepared for patient.
Preparing a room for the patient
Position (low for ambulatory, high for stretcher) and open the bed.
Assemble necessary equipment and supplies (hospital starter pack)
Assemble special equipment and supplies.
Adjust the physical environment of the room
admitting the patient to the unit
inventory of personal belongings
medication reconciliation (form is checked and filled out again with each transfer and on discharge to ensure that all medications have been correctly ordered)
Transfer within the hospital
Move patient's personal belongs to a new room.
Transfer patient chart, Kardex, care plan, and medications.
Notify other hospital departments of the move.
Give verbal report to the nurse in the new area.
Information on admission sheet
Name, address, and date of birth of patient
Gender and marital status
Name of admitting physician
Name of nearest relative
Occupation and employer
Financial status for health care payment
Date and time of admission/admitting diagnosis
transfer to an extended facility (long term)
A copy of the medical record is usually sent with the patient.
The original record, which is a legal document, remains at the hospital.
Detailed assessment and care plan is sent.
Patient's belongings, prescriptions, and appointment cards are sent to the facility with the patient.
The nurse often provides a verbal report to the new nurse.
Information included in verbal report
Patient name and age
Physicians and admitting diagnosis
Surgical procedure, if applicable
Current condition and manifestation
Allergies, medications, and treatments
Necessary laboratory data and special equipment
Nursing care priorities
Existence of advance directives
Tell whether the following statement is true or false.
When transferring a patient to a long-term care facility, the original chart, which is a legal document, remains at the hospital.
Answer: A. True
Rationale: When transferring a patient to a long-term care facility, the original chart, which is a legal document, remains at the hospital.
Discharge from a health care setting
patient changes from dependent to a more independent role
ensure that patient and family needs are consistently met as the patient from a care setting to home
begins on admission
coordination of care is nurse's responsibility
ensure family members are taught necessary skills
essential components of discharge planning
Assess strengths and limitations of the patient, family, or support person.
Assess the environment.
Implement and coordinate the plan of care.
Consider individual, family, and community resources.
Evaluate effectiveness of care
criteria for formal discharge plan and referrals
Lack of knowledge of treatment plan
Recently diagnosed chronic disease
Emotional or mental instability
Complex home health care regimen
Lack of available or appropriate referral sources
guidelines for discharge planning
Assess and identify health care needs.
Set goals with patient.
Teach patient and family.
Provide home health care referrals.
Evaluate discharge planning effectiveness (ongoing)
assessing and identifying health care needs
first step in discharge planning involves collecting and organizing data about the patient
evaluate patient's ability to carry out activities of daily living and instrumental activities of daily living
setting goals with the patient
set mutually and realistic
self-care at home
medications (info given verbally and writing)
should known how to contact providers of follow-up care and should know whom to call if they have questions
leaving against medical advice (AMA)
Patient is legally free to leave.
Choice carries a risk for increased illness or complications.
Patient must sign a release form.
Patient is informed of risks prior to signing form.
Patient's signature must be witnessed.
Form becomes part of medical record.
Which statement accurately describes part of the process involved when a patient leaves AMA?
A. The patient is not legally free to leave without being discharged.
B. The patient leaving AMA must sign a form releasing the nurse from legal responsibility for health status.
C. After signing the form, the patient should be informed of any possible risks involved with leaving AMA.
D. The patient's signature must be witnessed, and the form becomes part of the patient's record.
Answer: D. The patient's signature must be witnessed, and the form becomes part of the patient's record.
Rationale: A patient is legally free to leave the hospital against medical advice (AMA). The patient must sign a form releasing the physician and health care institution from legal responsibility and should be informed of any risks prior to signing the form.
home health care nursing
increasing with aging population
discharged from hospitals earlier
responsibility for care coordination remains with nurse (case management)
types of home health care agencies
Official or public agencies
Voluntary or private not-for-profit agencies
Private, proprietary agencies
Institution-based agencies - UPMC, Allegheny Health Network
must be certified by Medicare to receive reimbursement for services
official or public agencies
operated by governments
offer home care and disease prevention programs
voluntary or private nonprofit agencies
supported by donations
private, proprietary agencies
for profit organizations
paid for through health care insurance
institution based agencies
operate under hospital
examples of home health care services
High-technology pharmacy services (IV therapy, ventilator management, chemo)
Skilled professional/paraprofessional services (nursing care)
Custodial services (homemaking and housekeeping)
Home medical services
Community support services
referrals for home care
referral source- person who recommends home care services and supplies the agency with details about the patient's needs
orders for home care
must have an rder from a primary caregiver (physician, NP) and and approval for treatment
Medicare pays for home health care services
document ALL nursing interventions and write progress notes describing patient's condition
to be approved by medicare
confined to home
under care of a physician
plan of care established and reviewed by physician
pre-entry visit of home visit
referral nurse collects patient data (diagnosis, treatments ordered)
reviews the information and calls patient to schedule a visit
evaluate safety issues (neighborhood)
entry phase of home visit
The nurse identifies needs and determines interventions.
The nurse teaches the patient and caregivers (readiness to learn)
The nurse documents care given in the home.
gain trust of patient and family
accept living conditions
ask permission before using patient's home for activities (handwashing)
home health care interventions based on an individualized plan of care for each patient
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