Ch. 9- Continuity of Care

Formal discharge plan

-Lack of knowledge of treatment plan -Social isolation -Recently diagnosed chronic disease -Major surgery -Prolonged recuperation -Emotional or mental instability -Complex home care regimen -Financial difficulties -Lack of available or appropriate referral sources -Terminal illness *Patients need a plan!!

Against Medical advice

-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.

Transfer 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

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. (On admission-patients are scared, stressed, hurting, family may be at home. See BOX 9-3 page 176 3. How should you address them? What is their culture, background, language?)

Guidelines for discharge planning

Assess and identify healthcare needs. Set goals with patient. Teach patient and family. (3. Skills they need to learn to take care of the patient, diets that need to be followed, when should they call the doc?) Provide home healthcare referrals. Evaluate discharge planning effectiveness.

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 (Yes, ALL health care professionals are required to participate in care coordination, but especially nurses. Focus of "the right care at the right time")

ISBARQ

I - Introduction S - Situation B - Background A - Assessment R - Recommendation Q - Question and answer SBAR Used in Patient Hand-off and communication with physicians. I and Q are included in nurse to nurse report. S-include complaints, diagnoses, the plan, current needs B-include code status, meds, labs A-Most current assessment findings-reassuring and abnormal findings R-Pending labs or orders **See figure 9-4 page 170-face-to-fae; take your time; AT BEDSIDE (see video in Blackboard Page 171-problems that can occur in handoff-not enough time, lack of teamwork, respect, unable to focus during report...

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 Ensures a smooth transition between ambulatory or acute care and home health care or other types of health care settings in the patient's community. Depends on excellent communication as patients move from one caregiver or health care site to another. **Providing uninterrupted care between settings and levels of care. For example a patient may come through the ER, then go to the medsurg floor, then go to rehab, then go home with home health. Must communicate well during transfer reports to ensure a smooth transition.**

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 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.

Which of the following information is printed on the patient identification bracelet?

The patient identification number Rationale: The identification number, as well as the patient's and physician's name, is printed on the identification bracelet that is placed on the patient's wrist.

Which of the following statements accurately describes part of the process involved when a patient leaves AMA?

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 healthcare institution and should be informed of any risks prior to signing the form.

T/F? When transferring a patient to a long-term care facility, the original chart, which is a legal document, remains at the hospital.

True Rationale: When transferring a patient to a long-term care facility, the original chart, which is a legal document, remains at the hospital.