Chapter 9 Continuity of Care

A patient who decides to leave the hospital prior to completing the medical plan of care is leaving against medical advise.

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Based on the HEALTH insurance Portability and Accountability Act, all patients must sign a statement that they understand the protection of their medical information.

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CONTINUITY of care is the principle by which healthcare providers give appropriate, uninterpreted care and facilitate the patients transition between different settings and levels of care.

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Discharge PLANNING ensures that patient and family needs are consistently met as the patient moves from the acute care setting to care at home.

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Healthcare provided to people who live within a defined geographic area is known as COMMUNITY based healthcare.

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Transferring a Patient to a Long-Term Facility

A copy of the chart is usually sent with the patient; the original char remains at the hospital. Detailed assessment and care plan is sent The nurse often provides verbal report to the new nurse

Continuity of Care

A process by which healthcare providers give appropriate, uninterrupted care and facilitate the patients transition between different settings an levels of care.

Admission to the Hospital

Admission sheet becomes part of the medical record Bracelet is placed on wrist of patient (Required by the Joint Commission National safety standards) A nursing interview and physical assessment are conducted A room is prepared for the patient

Guidelines for Discharge Planning

Assess and identify healthcare needs Set goals with patient Teach patient and family Provide home healthcare referrals Evaluate discharge planning effectiveness Focused Assessment Guide

Essential Components of Discharge Planning

Discharge planning begins on admission Assess strengths and limitation of the patient, family or support person Assess the environment Implement the plan of care Consider individual, family and community resources Evaluate effectiveness of care

(T/F) In an ambulatory care facilities, patients receive healthcare services and remain in the facility overnight?

False

(T/F) It is the responsibility of the nurse to write an order for all referral services?

False

(T/F) When transferring a patient to a long-term facility, the medical chart should be sent to the new facility with the patient?

False (A copy is sent)

Community-based Care

Healthcare provided to people who live within a defined geographic area. Centered on individual and family healthcare needs Designed to meet the needs of people as they move inot between and among different healthcare settings within the overall healthcare system.

Criteria for Formal Discharge Plan on and Referrals

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

Transfer within Hospital Setting

Move patient's personal belongings to a new room Transfer patient char, Kardex, care plan and medications The nurse in the old area gives verbal report to the nurse in the new area.

Information Obtained on the Admission Sheet

Name, address and date of birth of patient Gender and marital status Name of admitting physician Name pf nearest relative Occupation and employer Financial status for health care payment Religious preference Date and time of admission/admitting diagnosis Identification number

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 risk prior to signing form Patients signature must be witnessed Form becomes part of medical record Releases the physicians and institution from legal responsibily

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

Admission to Ambulatory Care Setting

Patient receives healthcare 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. Goal is to provide healthcare services to patient who are able to provide self-care at home.

Preparing a Room for a Patient: Guidelines for Nursing Care

Position and open the bed Assemble necessary equipment and supplies Assemble special equipment as supplies Adjust the physical environment of the room Nurse may delegate; but is responsible that tasks are done

Role of the Nurse in community -based care

Provide continuity of care when patient moves from one level of care to another. Provide interventions Promote health Manage acute or chronic illness Promote self-care

Establishing an Effective Nurse-Patient Relationship

Reduce anxiety through therapeutic communication, teaching and acceptance. Remember that the patient has other concerns and needs other than medical ones. (Maslows) 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.

Important Roles of the Nurse

Teacher Collaborator Advocate

(T/F) It is the responsibility of the nurse to ensure that the hospital room is prepared for the patient?

True

(T/F) When a patients transferred to another unit, the nurse in the original area gives a report about the patient in the new area?

True