Exam II

When does discharge planning begin?

"Discharge planning is an essential component of facilitating the transition of the patient from the acute care to the community or home care setting, or for facilitating the transfer of the patient from one health care setting to another. A documented discharge plan is mandatory for patients who receive Medicare or Medicaid health insurance benefits. Discharge planning begins with the patient's admission to the hospital or health care setting and must consider the potential for necessary follow-up care in the home or another community setting. Several different personnel (e.g., social workers, home care nurses, case managers) or agencies may be involved in the planning process. The development of a comprehensive discharge plan requires collaboration between professionals at the referring agency and the home care agency, as well as other community agencies that provide specific resources upon discharge. The process involves identifying the patient's needs and developing a thorough plan to meet them. It is essential to have open lines of communication with family members to ensure their understanding and cooperation." (p. 16)

What is EBP?

"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett et al, 1996) Evidence-based practice (EBP) means using the best, research-proven assessments and treatments in our day-to-day client care and service delivery. This means each clinician undertakes to stay in touch with the research literature and to use it as a part of their clinical decision making. EBP also means weighing the value of each part of the research evidence with clinical data and informed client choice. In other words, we need to know what the research says, share this knowledge in an unbiased way with our clients, and with those clients make decisions about care based on our evaluation. To be accountable for our EBP we should record both the decisions made and the evidence we used. Following such decisions, an EBP clinician will also collect data to show that the clinical decision is helping address the client's goals. Taylor Ch 5, p 73

Rapid Cycle Testing Model

*Forming the Team* Including the right people on a process improvement team is critical to a successful improvement effort. Teams vary in size and composition. Each organization builds teams to suit its own needs. *Setting Aims* Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patients or other system that will be affected. *Establishing Measures* Teams use quantitative measures to determine if a specific change actually leads to an improvement. *Selecting Changes* Ideas for change may come from the insights of those who work in the system, from change concepts or other creative thinking techniques, or by borrowing from the experience of others who have successfully improved. *Testing Changes* The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting—by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method adapted for action-oriented learning (see figure on right side). *Implementing Changes* After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team may implement the change on a broader scale—for example, for an entire pilot population or on an entire unit. *Spreading Changes* After successful implementation of a change or package of changes for a pilot population or an entire unit, the team can spread the changes to other parts of the organization or in other organizations.

What are the differences between primary, secondary, and tertiary care?

*Primary Care:* Goal: Common health problems (sore throat, diabetes, arthritis, depression, or hypertension) and preventive measures (vaccinations, mammograms) that account for 80%-90% of visits to clinicians. Practitioner: family practice physicians, nurse practitioners, midwives Practice Sites: Family planning centers, primary care centers, urgent care centers, employment health centers Activities: Family planning, prenatal & well-baby care, immunization against specific disease, health risk screenings, diagnostic tests, health education, medications *Secondary Care:* Goal: Problems that require more specialized clinical expertise, such as hospital care for a patient with a myocardial infarction or stroke. Practitioner: Physicians in specialties such as internal medicine, pediatrics, neurology, psychiatry, advance practice nurses Practice Sites: Hospital based clinics, emergency departments, hospitals, psychiatric institutes, same-day surgery units Activities: Disease identification and management *Tertiary Care:* Goal: Management of rare and complex disorders such as pituitary tumors and congenital malformations. Practitioner: Subspecialist physicians such as cardiovascular surgeons, pediatric hematologists, advance practice nurses Practice Sites: Tertiary care medical centers Activities: Rare and complex disease management TABLE 8-2 Taylor pg. 147 Nurses in community-based practice provide preventive care at three levels: primary, secondary, and tertiary. Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detection, with prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening (Fig. 2-1) and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although they also address primary and secondary prevention. Brunner pg. 16

What nursing interventions did the institute of health improvement (IHI) include in "bundles"?

*VAP*: ventilator associated pneumonia - raise head of bead - daily sedative/daily assessment of readiness to extubate - PUD/DVT prophylaxis - daily oral care with clorhexidine *CAUTI*: catheter associated urinary tract infection-use strict aseptic technique - secure catheter - frequent assess urine color/odor/consistency - daily perineal care (soap and water) - maintain a closed system - follow instructions to obtain specimens *CLABSI*: central line associated blood stream infections - hand hygiene - maximal barrier precautions (ie gloves) - chlorhexidine skin antiseptics - optimal catheter site selection (no femora oven) - daily review of line *Pressure Ulcer*: - admission assessment (risk assessment) ie braden scale - reassess risk daily - inspect skin daily - manage moisture - optimize nutrition and hydration - minimize pressure

What are the *antecedents* of evidence based practice?

- *Problem identification - *Knowledge of importance of research in nursing* - *Identification of patient/family preferences and values.*

What *actions* are associated with the Nursing Process?

- Assessment - Diagnosing - Planning - Intervening - Evaluating outcomes *Assessing* - Collection, validation, and communication of patient data. *Diagnosing* - Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve. *Planning* - Specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses; and (2) related nursing interventions. *Implementing* - Carrying out the plan of care *Evaluating* - Measuring the extent to which the patient has achieved the outcomes specified in the plan of care; identifying factors that positively or negatively influenced outcome achievement; revising the plan of care if necessary (Taylor, 216).

Case Management

- Case management is another work design proposed to meet patient needs. - Case management is defined by the Case Management Society of America (CMSA) as "a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes" (CMSA, 2008-2012, para 58). - In case management, nurses address each patient individually, identifying the most cost- effective providers, treatments, and care settings possible. This requires the case manager to drill down and identify any barriers to adherence that other providers may miss (Primary Care—the New Frontier for Case Managers, 2013). - In addition, the case manager helps patients access community resources, learn about their medication regimen and treatment plan, and ensures that they have recommended tests and procedures. ~ While case management referrals often begin in the hospital inpatient setting, with length of stay (LOS) and profit margin per confinement used as measures of efficiency, case management now frequently extends to outpatient settings as well. Indeed, the new medical homes suggested as part of the Patient Care Protection and Affordable Care Act are likely to use case managers extensively. M&H 321

What is the goal of evidence based practice?

Aim—to provide best possible care based on best available research (caring sets nursing apart as a most trusted profession) The *benefits* of evidence-based practice- *Ability to access/use evidence from a variety of sources that will help improve client care* *Ensures credibility of the nursing profession* *Provides accountability for nursing care* EBP PPT #20 Notes

How does case management effect patient clinical outcomes?

Case managers may be nurses or may have backgrounds in other health professions, such as social work. The case manager coordinates the care of a caseload of patients through facilitating communication between nurses, other health care personnel who provide care, and insurance companies. In some settings, particularly the community setting, the case manager focuses on managing the treatment plan of the patient with complex conditions. The case manager may follow the patient throughout hospitalization and at home after discharge in an effort to coordinate health care services that will avert or delay rehospitalization. The caseload is usually limited in scope to patients with similar diagnoses, needs, and therapies-Brunner pg. 10

What is PICO? How does it relate to evidence base practice?

Components = Considerations *P* = Patient, population, or problem of interest Need for explicit description; may include setting, limiting to subgroups (such as by age). *I* = Intervention of interest The more defined, the more focused the search of the literature will be; may include exposure, treatment, patient perception, diagnostic test, or predicting factor. *C* = Comparison of interest Usually the comparison is to another treatment or the usual standard of care. *O* = Outcome of interest Specifically identifying the outcome to enable a literature search to find evidence that examined the same outcome, perhaps in different ways. (Taylor 38) Asking a clinical question in PICO format encourages finding best interventions by means of evidence based practice

Where did critical pathways originate from?

Critical Pathways-a strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care. These pathways reflect relatively standardized predictions of patients' progress for a specific diagnosis or procedure. Patient progress that differs from the critical pathway prompts a variance analysis. First developed in 1980s to reduce length of stay, critical pathways also provide a useful tool for monitoring quality of care. Advantage: provide some standardizing of care for patients w/similar diagnosis according to EBP and lead to improved patient outcomes. Disadvantage: Difficulty in accounting for and accepting what are often justifiable differentiations between unique patients who have deviated from their pathway. More documentation required. -Marquis pg. 218

What is a clinical pathway?

Critical pathways (also called clinical pathways and care pathways) are a strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care. These pathways reflect relatively standardized predictions of patients' progress for a specific diagnosis or procedure. For example, a critical pathway for a specific diagnosis might suggest an average length of stay of 4 days, with certain interventions completed by certain points on the pathway (much like a PERT diagram; see page 23). Patient progress that differs from the critical pathway prompts a variance analysis. Critical pathways are predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery. First developed in the 1980s as a tool to reduce length of stay, critical pathways also provide a useful tool for monitoring quality of care. Once the cost of a pathway is known, analyzing the cost-effectiveness of the pathway as well as the associated cost variances is possible. By using clinical and cost variance data, decisions on changing the pathway can be made with both clinical and financial outcome projections. The advantage of critical pathways is that they do provide some means of standardizing care for patients with similar diagnoses. Their weakness, however, is the difficulties they pose in accounting for and accepting what are often justifiable differentiations between unique patients who have deviated from their pathway. Critical pathway documentation also poses one more paperwork and utilization review function in a system already burdened with administrative costs. Despite these challenges, research suggests that critical pathways can standardize care according to evidence-based best practices, leading to improved patient outcomes. (Marquis Ch. 11, pg. 218)

What are diagnostic related groupings (DRG'S)?

DRG's- Rate-setting pps used by Medicare to determine payment rates for an inpatient hospital stay based on admission diagnosis. Each DrG represents a particular case type for which Medicare provides a flat dollar amount of reimbursement. This set rate may, in actuality, be higher or lower than the cost of treating the patient in a particular hospital. Marquis, L., B. (2015). Leadership Roles and Management Functions in Nursing: Theory and Application, 8th Edition. [CoursePoint]. Retrieved from https://coursepoint.vitalsource.com/#/books/9781469882765/

What is the goal of case management?

Describes a range of models for integrating health care services for individuals or groups. It is also at times referred to as discharge planning & begins the moment the a patient is admitted (sometimes before) to a health care organization. Case management involves multidisciplinary teams that assume collaborative responsibility for planning & assessing needs & coordinating, implementing & evaluating care for groups of clients from preadmission to discharge or transfer & recuperation. In the US Case managers are either nurses or social workers. (Nursing: A Concept Based Approach to Learning: North Carolina p. 2206 & Potter & Perry 8th ed. p. 19)—Healthcare Organizations PowerPoint 3 Slide 7 To plan and coordinate the client's progress through the various phases of care and to maximize fiscal outcomes... Case managers do coordinate the client's progress through various phases of care, but they are not responsible for providing counseling for family members. Case managers are responsible for maximizing fiscal outcomes. Brunner pg. 10

Why is it necessary to have multidisciplinary action plans (MAPS)?

EBP tools used for planning patient care may include not only bundles but also clinical guidelines, algorithms, care mapping, multidisciplinary action plans (MAPs), and clinical pathways. These tools are used to move patients toward predetermined outcomes. Algorithms are used more often in acute situations to determine a particular treatment based on patient information or response. Care maps, clinical guidelines, and MAPs (the most detailed of these tools) help to facilitate coordination of care and education throughout hospitalization and after discharge. Nurses who provide direct care have an important role in the development and use of these tools through their participation in researching the literature and then developing, piloting, implementing, and revising them as needed. Brunner pg. 10

What is the nurse's primary goal when using a clinical pathway?

First developed in the 1980s as a tool to reduce length of stay, critical pathways also provide a useful tool for monitoring quality of care. Once the cost of a pathway is known, analyzing the cost-effectiveness of the pathway as well as the associated cost variances is possible. By using clinical and cost variance data, decisions on changing the pathway can be made with both clinical and financial outcome projections. Critical pathways are predetermined courses of progress that patients should make after admission for a specific diagnosis or after a specific surgery. The advantage of critical pathways is that they do provide some means of standardizing care for patients with similar diagnoses. Despite these challenges, research suggests that critical pathways can standardize care according to evidence-based best practices, leading to improved patient outcomes. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

What are the *attributes* of evidence based practice?

From evidence based practice concept analysis diagram: - Replicability - Reliability - Validity - Individualized care Tanners Model: - Notice - Interpret - Responding - Reflecting a) in-action b) on-action SBAR: - Situation - Background - Assessment - Respond/Reflect

What is group building and who and what does the gatekeeper do?

Group Building and Maintenance Roles Group task roles contribute to the work to be done; group-building roles provide for the care and maintenance of the group. Examples of group-building roles include the following: Encourager. Accepts and praises all contributions, viewpoints, and ideas with warmth and solidarity. Harmonizer. Mediates, harmonizes, and resolves conflict. • Compromiser. Yields his or her position in a conflict situation. *Gatekeeper* - Promotes open communication and facilitates participation by all members. • Standard setter. Expresses or evaluates standards to evaluate group process. • Group commentator. Records group process and provides feedback to the group. • Follower. Accepts the group's ideas and listens to discussion and decisions. (Marquis 458)

Group Building Role

Group Building and Maintenance Roles Group task roles contribute to the work to be done; group-building roles provide for the care and maintenance of the group. Examples of group-building roles include the following: Encourager. Accepts and praises all contributions, viewpoints, and ideas with warmth and solidarity. Harmonizer. Mediates, harmonizes, and resolves conflict. -Compromiser. Yields his or her position in a conflict situation. Gatekeeper. Promotes open communication and facilitates participation by all members. • Standard setter. Expresses or evaluates standards to evaluate group process. • Group commentator. Records group process and provides feedback to the group. • Follower. Accepts the group's ideas and listens to discussion and decisions. Organizations need to have a mix of members—enough people to carry out the work and also people who are good at team building. One group may perform more than one function and group-building role. M&H 458

The Institute for Healthcare Improvement (IHI)

IHI is a nonprofit organization whose mission is adapted from the IOM's six aims for improvement: o ensuring that patient care is safe o effective o patient centered timely o efficient o equitable (IOM, 2001). The IHI launched its 5 Million Lives Campaign in 2007, anticipating that if evidence-based guidelines it advocated were voluntarily implemented by U.S. hospitals, 5 million lives would be saved from either harm or death over a 2-year period (IHI, 2011b). H&C p 9

Acute Care nurses now work closely with home health nurses and public health nurses. Because of this what nursing function has now increased in importance?

Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for patients who are hospitalized for relatively few days. Nurses in the community care for patients who need high-technology acute care services as well as long-term care in the home. The importance of effective discharge planning and quality improvement cannot be overstated. Acute care nurses must also work with community-based nurses and others in community settings to ensure continuity of care, (Hinkle, 9). Discharge planning is an essential component of facilitating the transition of the patient from the acute care to the community or home care setting, or for facilitating the transfer of the patient from one health care setting to another, (Hinkle, 16).

EBP Concepts

Nursing Care Primary, Secondary, Tertiary Attributes: 1) Replicability 2) Reliability 3) Validity 4) Individualized Care Antecedents 1) Problem Identification 2) Knowledge of Importance of 3) Research in Nursing 4) Identification of 5) Patient/Family Preferences and Values

What does Informatics (EHRs) Provide Nurses?

Nursing informatics is a relatively new specialty that has grown alongside the implementation of technology in the healthcare clinical setting. It is the "bridge between technology and patient. It is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This approach uses information structures, information processes, and information technology (ANA, 2008). As more nurses have become informatics, the tangible benefits of their efforts become clear: • Increases in the accuracy and completeness of nursing documentation • Improvement in the nurse's workflow and an elimination of redundant documentation • Automation of the collection and reuse of nursing data • Facilitation of the analysis of clinical data (Joint Commission indicators, core measures, federal- or state-mandated data and facility-specific data; Barthold, Duecker, Guinn, & MacCallum, 2009). H&C 12

Describe what informatics provides for nurses?

Nursing informatics is a relatively new specialty that has grown alongside the implementation of technology in the healthcare clinical setting. It is the "bridge between technology and patient. It is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This approach uses information structures, information processes, and information technology (ANA, 2008). As more nurses have become informaticists, the tangible benefits of their efforts become clear: Increases in the accuracy and completeness of nursing documentation Improvement in the nurse's workflow and an elimination of redundant documentation Automation of the collection and reuse of nursing data Facilitation of the analysis of clinical data (Joint Commission indicators, core measures, federal- or state-mandated data and facility-specific data; Barthold, Duecker, Guinn, & MacCallum, 2009). Hinkle, J. L., Cheever, K. H. (11/2013). Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th Edition. Pg.12 Taylor, C. (10/2014). Fundamentals of Nursing. Pg. 363

Primary, Secondary, Tertiary Prevention

Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detection, with prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening (Fig. 2-1) and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, although they also address primary and secondary prevention. H&C p 16

What is Capitation?

QUESTION: A nurse working in a physician's office prepares insurance forms in which the provider is given a fixed amount per enrollee of the health plan. What is the term for this type of reimbursement? 1. Capitation 2. Prospective payment system 3. Bundled payment 4. Rate setting ANSWER: 1. Capitation plans give providers a fixed amount per enrollee in the health plan in an effort to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services. (Taylor 162)

How do computerized standardized plans of care help nurses?

Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. They can provide an excellent basis for the initial plan if the nurse individualizes them. Resources for standardized plans include computerized plans, textbooks with prepared care plans, and agency-developed plans/maps/critical pathways. By using such standardized plans, the nurse is free to direct time and expertise to individualizing the plan. (Taylor 280) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

Clinical Pathways

Standardized interdisplinary care map for a specific diagnosis from the diagnosis-related group. Clinical pathways guide a patient's plan of care through attainment of specific clinical outcomes by the patient from admission to discharge. Benefits for the pathway include increased communication among members of the health care team, standardization of care, documentation and evaluation tools, decreased cost and length of stay, and increased patient and family satisfaction. Hinkle&Cheever, page10

How do Computerized Standardized Plans of Care help nurses?

Standardized plans of care are predetermined templates for specific patient problems. This makes the job of the nurse easier by providing easy access to a list of prioritized nursing diagnoses, goals, and interventions related to that specific patient problem. The nurse can then focus on simply tweaking the care plan to fit the specific patient situation. This makes care planning quick and simple (Taylor 280).

Hospitals now have computerized standardized plans of care. What are they for?

Standardized plans of care are predetermined templates for specific patient problems. This makes the job of the nurse easier by providing easy access to a list of prioritized nursing diagnoses, goals, and interventions related to that specific patient problem. The nurse can then focus on simply tweaking the care plan to fit the specific patient situation. This makes care planning quick and simple (Taylor 280). Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

What are the principles of the 5 million lives campaign?

The IHI launched its 5 Million Lives Campaign in 2007, anticipating that if evidence-based guidelines it advocated were voluntarily implemented by U.S. hospitals, 5 million lives would be saved from either harm or death over a 2-year period (Hinkle 10) Also see rapid cycle testing model

5 million lives campaign

The IHI launched its 5 Million Lives Campaign in 2007, anticipating that if evidence-based guidelines it advocated were voluntarily implemented by U.S. hospitals, 5 million lives would be saved from either harm or death over a 2-year period. Although the data are not fully analyzed as of this time, the credibility of IHI's quality improvement methods has encouraged hospitals to change their quality improvement processes and nursing practices.

What is the institute of health improvement (IHI), and what did they have to do with the 5 million lives campaign?

The Institute for Healthcare Improvement (IHI) is a nonprofit organization whose mission is adapted from the IOM's six aims for improvement; namely, ensuring that patient care is safe, effective, patient centered, timely, efficient, and equitable. The IHI launched its 5 Million Lives Campaign in 2007, anticipating that if evidence-based guidelines it advocated were voluntarily implemented by U.S. hospitals, 5 million lives would be saved from either harm or death over a 2-year period. Although the data are not fully analyzed as of this time, the credibility of IHI's quality improvement methods has encouraged hospitals to change their quality improvement processes and nursing practices.

How do Joint Commission and Medicaid services (CMS) evaluate hospitals?

The Joint Commission is a nonprofit organization that accredits hospitals and health care organizations. Over the past decade, it has annually updated and published its National Patient Safety Goals (NPSGs)—selected NPSGs include areas of patient safety concern that, if rectified, may have the most positive impact on improving patient care and outcomes. Recently adopted NPSGs revolve around identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing surgery-related mistakes. Each NPSG has implications for scrutinizing and perhaps changing and improving nursing practices. In addition, the Joint Commission provides evidence-based practice solutions for these NPSGs. An evidence-based practice (EBP) is a best practice derived from valid and reliable research studies that also considers the health care setting, patient preferences and values, and clinical judgment. The facilitation of EBP involves identifying and evaluating current literature and research findings, and then incorporating these findings into patient care as a means of ensuring quality care (Hinkle 9). In addition to the NPSGs, the Joint Commission, in cooperation with the Centers for Medicare and Medicaid Services (CMS), has developed sets of performance measures for hospitals called core measures. The core measures are used to gauge how well a hospital gives care to its patients who are admitted to seek treatment for a specific disease (e.g., heart failure) or who need a specific treatment (e.g., an immunization) as compared to evidence-based guidelines and standards of care. Benchmark standards of quality are used to compare the care or treatment that patients receive as compared to the best practice standards (Joint Commission, 2010). The percentage of the patients who receive the best care or treatment as specified at a given hospital is then calculated and reported so that hospitals can use those results to continue to improve their processes and performance until they consistently meet best practice standards 100% of the time (Hinkle 10).

Community nurses use a program called oasis outcome and instrument set (OASIS). What does it assess for in patients?

The Outcome and Assessment Information Set (OASIS) is the patient-specific, standardized assessment used in Medicare home health care to plan care, determine reimbursement, and measure quality. OASIS has been required for more than a decade to ensure that outcomebased care is provided for all care reimbursed by Medicare. This system uses six major domains—sociodemographic, environment, support system, health status, functional status, and behavioral status—and addresses selected health service utilization (Hinkle 17)

What changes in the health care system have created an increase need for nurses to practice in community based settings?

The role of nurses in community settings is ever expanding. The shift in health care delivery from inpatient to outpatient is a result of multiple factors, including new population trends (the growing number of older adults), changes in federal legislation, tighter insurance regulations, and decreasing hospital revenues. Transitions in the health care industry, the nursing profession, and changing patterns of disease have also affected the community setting (see Chapter 1 (Links to an external site.)Links to an external site.). Brunner pg. 15

EBP Questions with PICO

There are several different methods that can be used to ask clinical questions. The most common method is the PICO format (Melnyk & Fineout-Overholt, 2002), described in Table 5-6. See the accompanying display, PICO in Practice, for a sample of the development of a clinical question using PICO and the EBP decision-making process; additional samples are found in selected chapters of this text. TABLE 5-6 Asking Clinical Questions in PICO Format Components Considerations P ⁼ Patient, population, or problem of interest Need for explicit description; may include setting, limiting to subgroups (such as by age). I ⁼ Intervention of interest The more defined, the more focused search of the literature will be; may include exposure, treatment, patient perception, diagnostic test, or predicting factor. C ⁼ Comparison of interest Usually the comparison is to another treatment or the usual standard of care. O ⁼ Outcome of interest Specifically identifying the outcome to enable a literature search to find evidence that examined the same outcome, perhaps in different ways. Taylor p. 79

Why has there been an increase demand in the public health system concerning medical, nursing, and social services?

There has been an increase in demand in the public health system because there are more sick people that come to the hospital and there is a higher need for more medical, nursing, and social services to care for those patients. Nursing is an aging workforce and things are always changing in healthcare, so retired nurses can't just come back because for some it can be overwhelming for them to learn all over again. Also, Large numbers of newly insured patients resulting from federal health insurance reform, greater access to primary care and an emphasis on preventive care will also add to this increased demand for services.

Define Total patient care, functional nursing, modular or team nursing, primary care nursing?

Total Patient care: the oldest model for organizing patient care. nurse assumes total responsibility during their time on duty for meeting all needs of assigned patients. Sometimes referred to as case method of assignment because patients may be assigned as cases. Primary means of organizing patient care and provides nurses with high autonomy and responsibilities. disadvantages of total patient care delivery occurs when the nurse inadequately prepares or is too inexperienced to provide total care to the patient P 314 Marquis, L., B. (2015). Leadership Roles and Management Functions in Nursing: Theory and Application, 8th Edition. Functional method of delivering nursing care : Unskilled personnel were needed to assist in patient care and trained to do simple tasks rather than care for specific patients. examples of functional nursing include: taking blood pressures, administering medications, changing linens, and bathing. Most administrators consider functional nursing to be economical and as a efficient means of providing care. Major advantages is efficiency and tasks are completed quickly with little confusion regarding responsibilities. Functional nursing allows care to be provided, and has been proven that the structure works well and is still very much practiced. Functional nursing may lead to fragmented care and the possibility of overlooking patient priority needs. may lead to low job satisfaction due to some workers feeling unchallenged or under stimulated. p.315-316 Marquis, L., B. (2015). Leadership Roles and Management Functions in Nursing: Theory and Application, 8th Edition. Team nursing : Developed to reduce fragmented care to accompany team nursing. Occurs when an ancillary personnel collaborative in providing care to a group of patients under the direction of a professional nurse. As a team leader, the nurse is responsible for knowing the condition and nneds for all patients assigned to team and plan individual care. duties vary depending on patients needs and workload. May include assisting team members, giving direct personal care to patients and teaching, or coordinating patient activites. Team usually involves no more than 5 people and allows members to contribute their own expertise and skills. Teams allow group members to have autonomy when preforming tasks but allows sharing of responsilbity and accountability collectively . Disadvantages of team nursing is associated with improper implementation rather than the philosophy itself. insuffient time is allowed for team communication and planning, and can lead to blurred lines of responsibility errors and fragmented patient care. to be an effective team nursing leader, the nurse leade must be an excellent practioner and have good communication adn organizational management and leadership skills. p316-317 Marquis, L., B. (2015). Leadership Roles and Management Functions in Nursing: Theory and Application, 8th Edition. Modular nursing: uses a mini team with members of modular nursing team sometimes called care pairs. Patient care units are typicall divided into modules or district assignments based on location of patients. P 318 Primary Nursing: relationship based on nursing; uses the same concepts of total patient care and brings the RN back to the bedside to provide clinical care. Primary nuse assumes the 24 hour responsibility for planning the care of one or more patients from admission (start of treatment) to discharge (treatment end). primary nurse provides total direct care of that patient. integeral responsibilty of the primary nurse is to establish clear communication among patient, physican associate nurses and other team members, and care plan. disadvantages include problems with implementation or inadequately prepared and imcompentent nurses. p319-320 Marquis, Bessie L. Leadership Roles and Management Functions in Nursing: Theory and Application, 8th Edition.

What changes have created a need for Community Nursing?

o Both the prospective payment system and Medicaid reimbursement and regulatory policies appear to have substantially changed the nature of long-term care at a time when demand for such care is increasing. o Physicians and other care givers must recognize that different types of care are now required of long-term care providers. o Payers, regulators, and providers alike must understand the need for a careful analysis of the way we pay for long-term care and ensure its quality. o CNPs are now being given opportunity to work in the inner city and clinics of the underserved. CNPs fill the gap for lack of PCPs.

Certified Nurse Practitioner

o CNPs who are educationally prepared with a population focus in adult-gerontology or pediatrics receive additional focused training in primary care or acute care. CNPs may practice autonomously, diagnosing and treating individual patients with undifferentiated clinical manifestations as well as those with confirmed diagnoses. o The scope of CNP practice includes health promotion and education, disease prevention, and the (MEDICAL)diagnosis and management of acute and chronic diseases for individual recipients of care. THEY CAN GIVE CARE IN PLACE OF PCPs. H&C p 12

Case Management

o Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. o Under this system, the responsibility for meeting patient needs rests with one person or a team whose goals are to provide the patient and family with access to required services, to ensure coordination of these services, and to evaluate how effectively these services are delivered. o Case managers may be nurses or may have backgrounds in other health professions, such as social work. o The case manager coordinates the care of a caseload of patients through facilitating communication between nurses, other health care personnel who provide care, and insurance companies. o In some settings, particularly the community setting, the case manager focuses on managing the treatment plan of the patient with complex conditions. The case manager may follow the patient throughout hospitalization and at home after discharge in an effort to coordinate health care services that will avert or delay rehospitalization. o The caseload is usually limited in scope to patients with similar diagnoses, needs, and therapies (Case Management Society of America, 2011). H&C p10

Why is there increased demand for public health system of medical, nursing, and social services?

o Community-based nursing is a philosophy of care in which the care is provided as patients and their families move among various service providers outside of hospitals. It focuses on promoting and maintaining the health of individuals and families, preventing and minimizing the progression of disease, and improving quality of life (Stanhope & Lancaster, 2012). Community health nurses provide direct care to patients and families and use political advocacy to secure resources for aggregate populations (e.g., the older adult population). o Community health nurses have many roles, including epidemiologist, case manager, coordinator of services provided to a group of patients, occupational health nurse, school nurse, visiting nurse, hospice nurse, or parish nurse. (In parish nursing, also called faith community nursing, the members of a faith-based community, typically the parish or the community the parish serves, are the recipients of care.) o These roles have one element in common: a focus on community needs as well as the needs of individual patients. The primary concepts of community-based nursing care are preventive care and self-care within the context of culture and community. H&C 16

Actions of Nursing Process

o Implementing carrying out the plan of care o Assist patients to achieve desired outcomes—promote wellness, prevent disease and illness, restore health, and facilitate coping with altered functioning. - Carry out the plan of care. - Continue data collection, and modify the plan of care as needed. - Document care.

Primary Care Nursing

o In primary nursing, the primary nurse assumes 24-hour responsibility for planning the care of one or more patients from admission or the start of treatment to discharge or the treatment's end. During work hours, the primary nurse provides total direct care for that patient. When the primary nurse is not on duty, associate nurses, who follow the care plan established by the primary nurse, provide care. ~ Many experts have suggested that the role of the primary nurse should be limited to RNs; however, Manthey (2009) argues that primary nursing can succeed with a diverse skill mix just as team nursing or any other model can succeed with an all-RN staff. Primary nursing structure is shown in Figure 14.4. ~ Although job satisfaction is high in primary nursing, this method is difficult to implement because of the degree of responsibility and autonomy required of the primary nurse. However, for these same reasons, once nurses develop skill in primary nursing care delivery, they often feel challenged and rewarded. ~ Disadvantages to this method, as in team nursing, lie primarily in improper implementation. An inadequately prepared or incompetent primary nurse may be incapable of coordinating a multidisciplinary team or identifying complex patient needs and condition changes. M&H 319

Primary goal of clinical pathways

o Integrated care pathways are care plans that detail the essential steps in the care of patients with a specific clinical problem and describe the expected progress of the patient; o They exist for over 45 conditions or procedures, and national users' groups exist to give advice and support in their use; o They aim to facilitate the introduction into clinical practice of clinical guidelines and systematic, continuing audit into clinical practice: they can provide a link between the establishment of clinical guidelines and their use; o They help in communication with patients by giving them access to a clearly written summary of their expected care plan and progress over time

Advanced Practice Nursing Roles

o Nurses may pursue generalist master's degrees in nursing that prepare them to practice as CNLs, as described previously. Alternatively, they may enroll in specialized graduate nursing education programs and pursue role preparation as certified nurse practitioners (CNPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs), all of whom are collectively identified as advanced practice registered nurses (APRNs) (APRN Consensus Work Group & the National Council of State Boards of Nursing [NCSBN] APRN Advisory Committee, 2008). o Each of these programs prepares APRNs to demonstrate competence with a focused population that is the recipient of care. The population foci include family, adult-gerontology, neonatal, pediatrics, women's health, and psychiatric-mental health (APRN Consensus Work Group & the NCSBN APRN Advisory Committee, 2008). o The APRN roles that are most relevant to medical-surgical nursing are the CNP and CNS roles, and the most relevant population focus is adult-gerontology. H&C 11

IHI and its partners in the Campaign encouraged the following steps to reduce harm and deaths:

o Prevent Pressure Ulcers by reliably using science-based guidelines o Reduce MRSA infection through basic infection control o Prevent Harm from High-Alert Medications o Reduce Surgical Complications by the Surgical Care Improvement Project (SCIP) o Deliver reliable EBP for Congestive Heart Failure to reduce readmission o Get Boards on board by accelerating the improvement of care o Support to hospitals in interventions of the 100,000 Lives Campaign: -Deploy Rapid Response Teams at the first sign of patient decline -Deliver reliable EBP for AMIs-prevent deaths from heart attack -Prevent Adverse Drug Events (ADEs) by implementing medication reconciliation -Prevent Central Line Infections by implementing "Central Line Bundle" -Prevent Surgical Site Infections by delivering correct perioperative antibiotics -Prevent Ventilator-Associated Pneumonia by implementing "Ventilator Bundle"

How do Joint Commission and Medicare & Medicaid services (CMS) evaluate hospitals?

o The Joint Commission is a nonprofit organization that accredits hospitals and health care organizations. Over the past decade, it has annually updated and published its National Patient Safety Goals (NPSGs)—selected NPSGs include areas of patient safety concern that, if rectified, may have the most positive impact on improving patient care and outcomes. Recently adopted NPSGs revolve around identifying patients correctly, improving staff communication, using medications safely, preventing infections, identifying patient safety risks, and preventing surgery-related mistakes. Each NPSG has implications for scrutinizing and perhaps changing and improving nursing practices. In addition, the Joint Commission provides evidence-based practice solutions for these NPSGs. An evidence-based practice (EBP) is a best practice derived from valid and reliable research studies that also considers the health care setting, patient preferences and values, and clinical judgment. The facilitation of EBP involves identifying and evaluating current literature and research findings, and then incorporating these findings into patient care as a means of ensuring quality care (Hinkle 9). o In addition to the NPSGs, the Joint Commission, in cooperation with the Centers for Medicare and Medicaid Services (CMS), has developed sets of performance measures for hospitals called core measures. The core measures are used to gauge how well a hospital gives care to its patients who are admitted to seek treatment for a specific disease (e.g., heart failure) or who need a specific treatment (e.g., an immunization) as compared to evidence-based guidelines and standards of care. Benchmark standards of quality are used to compare the care or treatment that patients receive as compared to the best practice standards (Joint Commission, 2010). The percentage of the patients who receive the best care or treatment as specified at a given hospital is then calculated and reported so that hospitals can use those results to continue to improve their processes and performance until they consistently meet best practice standards 100% of the time (Hinkle 10).

Clinical Nurse Specialist

o The primary role of CNSs, on the other hand, is to integrate care across the health care continuum through three spheres of influence the patient, the nurse, and the health care system. o In each of these spheres of influence, the goal of CNS practice is to continuously monitor and improve aggregate patient outcomes and nursing care o CNSs' role as having five major components: clinical practice, education, management, consultation, and research. o CNSs practice in various settings, including the community and the home, although most practice in acute care settings. H&C 12

When does discharge planning begin?

~ "Discharge planning is an essential component of facilitating the transition of the patient from the acute care to the community or home care setting, or for facilitating the transfer of the patient from one health care setting to another. A documented discharge plan is mandatory for patients who receive Medicare or Medicaid health insurance benefits. Discharge planning begins with the patient's admission to the hospital or health care setting and must consider the potential for necessary follow-up care in the home or another community setting. Several different personnel (e.g., social workers, home care nurses, case managers) or agencies may be involved in the planning process. ~ The development of a comprehensive discharge plan requires collaboration between professionals at the referring agency and the home care agency, as well as other community agencies that provide specific resources upon discharge. The process involves identifying the patient's needs and developing a thorough plan to meet them. It is essential to have open lines of communication with family members to ensure their understanding and cooperation." (H&C 16)

Capitation

~ A method of payment for health services in which a physician or hospital are paid a fixed amount is paid per enrollee to cover a defined scope of services for a defined population set-aka covered lives for a defined period of time, regardless of actual number or nature services provided; capitation may be used by purchasers to pay health plans or by plans to pay providers. Marquis p 209 ~ Another frequent hallmark of managed care is capitation, whereby providers receive a fixed monthly payment regardless of services used by that patient during the month. If the cost to provide care to someone is less than the capitated amount, the provider profits. If the cost is greater than the capitated amount, the provider suffers a loss. The goal, then, for capitated providers is to see that patients receive the essential services to stay healthy or to keep from becoming ill but to eliminate unnecessary use of health-care services. Critics of capitation argue that this reimbursement strategy leads to under-treatment of patients. Marquis p 221

Where did Critical Pathways originate from?

~ Critical Pathways-a strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care. These pathways reflect relatively standardized predictions of patients' progress for a specific diagnosis or procedure. Patient progress that differs from the critical pathway prompts a variance analysis. First developed in 1980s to reduce length of stay, critical pathways also provide a useful tool for monitoring quality of care. ~ Advantage: provide some standardizing of care for patients w/similar diagnosis according to EBP and lead to improved patient outcomes. ~ Disadvantage: Difficulty in accounting for and accepting what are often justifiable differentiations between unique patients who have deviated from their pathway. More documentation required. -Marquis pg. 218

What are DRGs?

~ In 1983, Medicare converted to a prospective payment plan based on patient classification categories, called . The federal government implemented DRGs in an effort to control rising health care costs. The plan pays the hospital a fixed amount that is predetermined by the medical diagnosis or specific procedure rather than by the actual cost of hospitalization and care. Medicare was expanded in 1988 to include catastrophic care costs and expensive medications. ~ In 2007, based on changes in DRGs made by the Centers for Medicare and Medicaid Services (CMS), the reimbursement to hospitals became based on severity of illness and projected cost of care. The plan pays only the amount of money preassigned to a treatment for the diagnosis (e.g., an appendectomy); if the cost of hospitalization is greater than that assigned, the hospital must absorb the additional cost. If the cost is less than that assigned, the hospital makes a profit. ~ In addition, Medicare no longer reimburses hospitals for conditions that result from preventable errors and lead to increased costs. Such conditions include pressure ulcers, injuries caused by falls, infections associated with indwelling urinary catheters, vascular catheter-associated infections, infections of the mediastinum after coronary artery bypass graft, air embolisms, adverse reactions to incompatible blood infusions, and sponges or instruments left inside a patient during surgery. Taylor 152

Modular or Team Nursing

~ Modular Nursing Team nursing, as originally designed, has undergone much modification in the last 30 years. Most team nursing was never practiced in its purest form but was instead a combination of team and functional structure. ~ More recent attempts to refine and improve team nursing have resulted in many models including modular nursing. Most team nursing was never practiced in its purest form but was instead a combination of team and functional structure. ~ Modular nursing uses a mini-team (two or three members with at least one member being an RN), with members of the modular nursing team sometimes being called care pairs. In modular nursing, patient care units are typically divided into modules or districts and assignments are based on the geographical location of patients. ~ Keeping the team small in modular nursing and attempting to assign personnel to the same team as often as possible should allow the professional nurse more time for planning and coordinating team members. In addition, a small team requires less communication, allowing members better use of their time for direct patient care activities. M&H, Ch.14, (Nursing Care Delivery System), p. 318.

Why are muti-disciplinary action plans (MAPs) necessary?

~ Multidisciplinary Action Plans (MAP) plan patient care combining Critical pathways and the nursing care plan. Indicates TIME when interventions should occur. Case managers often manage care using critical pathways (Chapter 10) and multidisciplinary action plans (MAPs) to plan patient care. The care MAP is a combination of a critical pathway and a nursing care plan. In addition, the care MAP indicates times when nursing interventions should occur. All health-care providers follow the care MAP to facilitate expected outcomes. If a patient deviates from the normal plan, a variance is indicated. A variance is anything that occurs to alter the patient's progress through the normal critical path. (M&H p. 321)

Outcome and Assessment Information Set (Oasis):

~ Older adults are the most frequent users of home care expenditures financed by Medicare, which allows nurses to manage and evaluate care of seriously ill patients who have complex, labile conditions and are at high risk for re-hospitalization. ~ Each funding source has its own requirements for services rendered, number of visits allowed, and amount of reimbursement the agency receives. ~ The Omaha System's care documentation referred to as the Outcome and Assessment Information Set (OASIS) has been required for more than a decade to ensure that outcome-based care is provided for all care reimbursed by Medicare. ~ This system uses six major domains—sociodemographic, environment, support system, health status, functional status, and behavioral status—and addresses selected health service utilization (Martin, Monsen, & Bowles, 2011; Tullai-McGuinness, Madigan, & Fortinsky, 2009). (H&C p. 17)

Functional Nursing

~ The functional form of organizing patient care was thought to be temporary, as it was assumed that when the war ended, hospitals would not need ancillary workers. However, the baby boom and resulting population growth immediately following World War II left the country short of nurses. Thus, employment of personnel with various levels of skill and education proliferated as new categories of health-care workers were created. ~ Currently, most health-care organizations continue to employ health-care workers of many educational backgrounds and skill levels. Most administrators consider functional nursing to be an economical and efficient means of providing care. This is true if quality care and holistic care are not regarded as essential. ~ A major advantage of functional nursing is its efficiency; tasks are completed quickly, with little confusion regarding responsibilities. Functional nursing does allow care to be provided with a minimal number of RNs, and in many areas, such as the operating room, the functional structure works well and is still very much in evidence. Long-term care facilities also frequently use a functional approach to nursing care. ~ During the past decade, however, the use of unlicensed assistive personnel (UAP), also known as nursing assistive personnel, in health-care organizations has increased. Many nurse administrators believe that assigning low-skill tasks to UAP frees the professional nurse to perform more highly skilled duties and is therefore more economical; however, others argue that the time needed to supervise the UAP negates any time savings that may have occurred. ~ Most modern administrators would undoubtedly deny that they are using functional nursing, yet the trend of assigning tasks to workers, rather than assigning workers to the professional nurse, resembles, at least in part, functional nursing. M&H 315

Total Patient Care

~ With total patient care, nurses assume total responsibility during their time on duty for meeting all the needs of assigned patients. Total patient care nursing is sometimes referred to as the case method of assignment because patients may be assigned as cases, much like private-duty nursing was historically carried out. Indeed, at the turn of the 19th century, total patient care was the predominant nursing care delivery model. Care was generally provided in the patient's home, and the nurse was responsible for cooking, house cleaning, and other activities specific to the patient and family in addition to traditional nursing care. During the Great Depression of the 1930s, however, people could no longer afford home care and began using hospitals for care that had been performed by private-duty nurses in the home. ~ During that time, nurses and students were the caregivers in hospitals and in public health agencies. As hospitals grew during the 1930s and 1940s, providing total care continued to be the primary means of organizing patient care. This method of assignment is still widely used in hospitals and home health agencies. This organizational structure provides nurses with high autonomy and responsibility. Assigning patients is simple and direct and does not require the planning that other methods of patient care delivery require. ~ The lines of responsibility and accountability are clear. The patient theoretically receives holistic and unfragmented care during the nurse's time on duty. Each nurse caring for the patient can, however, modify the care regimen. Therefore, if there are three shifts, the patient could receive three different approaches to care, often resulting in confusion for the patient. ~ To maintain quality care, this method requires highly skilled personnel and thus may cost more than some other forms of patient care. This method's opponents argue that some tasks performed by the primary caregiver could be accomplished by someone with less training and therefore at a lower cost. ~ The greatest disadvantage of total patient care delivery occurs when the nurse is inadequately prepared or too inexperienced to provide total care to the patient. In the early days of nursing, only registered nurses (RNs) provided care; now, many hospitals assign LVNs/LPNs as well as unlicensed health-care workers to provide much of the nursing care. Because the coassigned RN may have a heavy patient load, little opportunity for supervision may exist and this could result in unsafe care. M&H, 313-314