Chapter 9 Care Coordination and Continuity in Health

Continuity of Care Process by which health care providers give appropriate, uninterrupted care and

Care Coordination Care transition: a continuous process in which a patient's care shifts from

The U. S. Department of Defense Handoff Model Copyright © 2015 Wolters Kluwer •

Care Coordination Ring Copyright © 2015 Wolters Kluwer • All Rights Reserved

ISBARQ Method of Patient Hand-off • I – Introduction • S – Situation •

Information Included in Verbal Report SBAR • Patient name and age • Physicians and

Role of the Nurse in Community-Based Care ØProvide continuity of care when patient moves

Qualities of the Community-Based Nurse üKnowledgeable and skilled üIndependent in making decisions üAccountable Copyright

Roles of the Community-Based Nurse ØPatient advocate ØCoordinator of services ØPatient and family educator

Vulnerable Populations ØPeople with disabilities or multiple chronic conditions ØPeople with mental illnesses or

Establishing an Effective Nurse–Patient Relationship • Reduce anxiety through therapeutic communication, teaching, and acceptance.

Admission to Ambulatory Care Setting • Patient receives health care services but does not

Admission to the Hospital • Admission sheet becomes part of the medical record. •

Information Obtained on the Admission Sheet (p. 176 -178) • Name, address, and date

Preparing a Room for a Patient Box 9 -1 p. 177 • Position and

Transfer Within Hospital Setting • Move patient’s personal belongs to a new room. •

Transferring a Patient to a Long-Term Facility • A copy of the medical record

Essential Components of Discharge Planning • Begins on admission • Assess strengths and limitations

Criteria for Formal Discharge Plan and Referrals ØLack of knowledge of treatment plan ØEmotional

Guidelines for Discharge Planning • Assess and identify health care needs. • Set goals

Leaving AMA • Patient is legally free to leave. • Choice carries a risk

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Continuity of Care Process by which health care providers give appropriate, uninterrupted care and facilitate the patient’s transition between different settings and levels of care • Depends on excellent communication as patients move from one caregiver or health care site to another. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Care Coordination Care transition: a 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, and especially nurses • Aim: • Link patients with resources in the community to enhance their well-being • Improve information exchange • Reduce fragmentation and duplication of services Copyright © 2015 Wolters Kluwer • All Rights Reserved

ISBARQ Method of Patient Hand-off • I – Introduction • S – Situation • B - Background • A – Assessment • R – Recommendation • Q - Question and answer L n r ea This will be on your exam and final!!! t i ve o L it, Copyright © 2015 Wolters Kluwer • All Rights Reserved v i , L ! ! t i e

Information Included in Verbal Report SBAR • 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 Copyright © 2015 Wolters Kluwer • All Rights Reserved

Role of the Nurse in Community-Based Care ØProvide continuity of care when patient moves from one level of care to another or from one setting to another. ØProvide interventions to promote health. ØManage acute or chronic illness. ØPromote self-care. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Vulnerable Populations ØPeople with disabilities or multiple chronic conditions ØPeople with mental illnesses or substance abuse ØCultural, racial and ethnic minorities ØThe rural and urban poor (poverty and homelessness) ØUndocumented immigrants Copyright © 2015 Wolters Kluwer • All Rights Reserved

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. • Box 9 -3 p 176 Copyright © 2015 Wolters Kluwer • All Rights Reserved

Admission to Ambulatory Care Setting • Patient receives health care services but does not remain overnight (more than 24 hours). • 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. • Goal is to provide healthcare services to patients who are able to provide self-care at home. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Admission to the Hospital • Admission sheet becomes part of the medical record. • Bracelet is placed on wrist of patient. • A nursing interview and physical assessment are conducted. (Required by The Joint Commission/national safety standards) • A room is prepared for patient. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Information Obtained on the Admission Sheet (p. 176 -178) • 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 • Religious preference • Date and time of admission/admitting diagnosis • Identification number Copyright © 2015 Wolters Kluwer • All Rights Reserved

Preparing a Room for a Patient Box 9 -1 p. 177 • Position and open the bed. • Assemble necessary equipment and supplies. • Assemble special equipment and supplies. • Adjust the physical environment of the room. • Nurse may delegate; but is responsible that tasks are done Copyright © 2015 Wolters Kluwer • All Rights Reserved

Transfer Within Hospital Setting • Move patient’s personal belongs to a new room. • Transfer patient chart, Kardex, care plan, and medications. • Give verbal report (SBAR) to the nurse in the new area. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Transferring a Patient to a Long-Term Facility • 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 (SBAR) to the new nurse. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Essential Components of Discharge Planning • Begins on admission • 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. Copyright © 2015 Wolters Kluwer • All Rights Reserved

Criteria for Formal Discharge Plan and Referrals ØLack of knowledge of treatment plan ØEmotional or mental instability ØComplex home health care regimen ØSocial isolation ØRecently diagnosed chronic disease ØFinancial difficulties ØMajor surgery ØLack of available or appropriate referral sources ØProlonged recuperation ØTerminal illness Copyright © 2015 Wolters Kluwer • All Rights Reserved

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. • Focused Assessment Guide 9 -1 p. 180 (review only) Copyright © 2015 Wolters Kluwer • All Rights Reserved

Leaving 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. Copyright © 2015 Wolters Kluwer • All Rights Reserved

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