CH. 12 Interprofessional Collaborative Practice and Care Coordination Across Settings

Vulnerable Populations

-People with disabilities or multiple chronic conditions -People with mental illnesses or substance use -Cultural, racial, and ethnic minorities -People experiencing poverty in rural and urban areas -Those who are homeless -Undocumented immigrants

Nurses working in the community

-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. -Promote self-care.

Why is it important for the home health nurse to inform the health care agency of the nurse's daily itinerary?

Supports suggested safety precautions for the nurse when making a home care visit

When preparing to transfer an older adult client back to the long-term care facility where the client has been for several years, it is the primary responsibility of the nurse to:

provide for the coordination and continuity of care by the health care providers.

The nurse understands that planning for discharge actually begins at admission to the facility. The purpose of discharge planning is best described as:

providing continuity of care that is goal directed.

Children can experience _____ if gardians are not present during hospitalization.

seperation anxiety

Home referrals may be made after

the education process, based on orders provided by the health care provider

In the entry phase

the nurse develops rapport with the client and family, makes assessments, determines nursing diagnoses, establishes desired outcomes (along with the client and family), plans and implements prescribed care, and provides teaching

base line data example

vital signs, height, weight, allergy status

When a multidisciplinary team is involved in meeting the home care needs of a client, who is the person responsible for the coordination of the care provided?

The registered nurse

clients in distressor or who have mental status changes might need to have who present to provide necessary information

a Family member

Fragmentation of care is more likely when

a client requires services from multiple individuals and disciplines

Health History

a collection of subjective information that provides information about the patient's health status

Community-Based Health Care

a model of care to reach all in a community and it focuses on assisting individuals and communities with achieving a healthy living environment

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

Admission equipment

Document forms, equipment to measure vital signs, a pulse oximeter and hospital attire for client

A client newly diagnosed with cancer has been assigned a nurse navigator. The nurse offers additional explanation about this nurse's role when the client makes which statements? Select all that apply

"I would rather have someone from the team caring for me." "I'm relieved to know that you will be driving me to my treatments."

The home care nurse asks the client and family about their socioeconomic status, culture, and beliefs. Which is the best response by the nurse when the family asks why those questions are being asked?

"I want to ensure your care meets your unique needs."

A nurse is using the SBAR approach for handoff communication when transferring a client to the critical care unit. Which statement would the nurse include as part of the recommendation?

"The client is scheduled for a cardiac catheterization in about an hour and needs monitoring every 15 minutes."

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family lives in another city. When assessing for the factor that will have the greatest effect on the client's home care management, the nurse will ask what question?

"Who are the people in your life that you can rely on for support?

Telehealth

-Also referred to as telemedicine -Use of electronic information and telecommunication technologies to provide care remotely -Include wellness visits; prescriptions for medicine; dermatologic; eye exams; nutrition counseling; mental health counseling; some urgent care conditions

Essential Components of Discharge Planning to other facilities

-Assess strengths and limitations of the patient, family, or support person -Assess the environment -Implement and coordinate the care plan -Consider individual, family, and community resources -Evaluate effectiveness of care

Examples of Home Health Care Services

-High-technology pharmacy services -Skilled professional/paraprofessional services -Custodial services -Hospice services -Home medical services -Community support services

Information Obtained on the Admission Sheet

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

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 usually take place before patients enter the setting. -Goal is to provide healthcare services to patient who are able to provide self-care at home. Individuals go to ambulatory settings for health promotion, health maintenance, or medical or surgical treatment.

discharge planning

-should begin when client is admitted (with the exception of LTC) -assess if the client will be able to return home and/or if they will need assistance at home -assess residence to see if adaptations or specific equipment will be necessary -make referral to social worker if needed to arrange for community services -communicate client health status and needs to community service providers -if client chooses to leave before discharged, notify provider and have pt sign off

Guidelines for Discharge Planning

1. Assess and identify healthcare needs. 2. Set goals with patient. 3. Teach patient and family. 4. Provide home healthcare referrals. 5. Evaluate discharge planning effectiveness.

Qualities of the Community-Based Nurse

1. Knowledgeable & Skilled 2. Independent in making decisions 3. Accountable

Criteria for Formal Discharge Plan and Referrals

1. Lack of knowledge of treatment plan 2. Social isolation 3. Recently diagnosed chronic disease 4. Major surgery 5. Prolonged recuperation 6. Emotional or mental instability 7. Complex home health care regimen 8. Financial difficulties 9. Lack of available or appropriate referral sources 10. Terminal illness

Roles of the Community-Based Nurse

1. Patient advocate 2. Coordinator of services 3. Patient and family educator

Patient navigator

A person who identifies patients' needs and barriers and assists by coordinating care and identifying community and healthcare resources to meet the needs. oNurse, social worker, or lay person oFocuses on the support aspects of care

SBAR communication

A stands for assessment (current provider's assessment of the situation);

What is a Third-Party Payer

A third-party payer is an entity (other than the patient or healthcare provider) that pays for healthcare services. This can include insurance companies, government programs (like Medicare or Medicaid), and employer-sponsored health plans. They typically negotiate rates and pay for services on behalf of the patient. Paying for healthcare services on behalf of the patient. Common third-party payers include insurance companies and government programs. Negotiating healthcare service rates.

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?

A.The nurse discusses the patient's background

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. A room is prepared for patient. Admitting the patient to the unit Completing medication reconciliation

SBAR communication

B stands for background (vital signs, mental and code status, list of medications, and lab results);

admissions assessment

Baseline data Biographical info Clients reason for seeking health care Present illness and findings Health History Family history Psychosocial Assessment Nutrition Spiritual health/quality of life concerns Review Systems Safety Assessment Discharge information

What is Bereavement Care:

Bereavement care involves supporting individuals who are grieving the death of a loved one. This support can be provided by healthcare professionals, such as nurses or counselors, and focuses on helping individuals cope with loss and work through the grieving process. Providing support to individuals grieving a loss. Helping cope with the emotional impact of bereavement. Offered by healthcare professionals and support groups.

One significant change in the health care delivery system in recent years is earlier hospital discharges. What is one result of earlier hospital discharges?

Clients with high home care needs are being discharged into the community.

A single parent age 17 years, with one child and pregnant with a second, has the mental age of a 12-year-old. The home care nurse's greatest concern in caring for this client should be the client's ability to do which?

Cognitively understand how to care for the children The cognitive ability to understand how to organize work, manage financial responsibilities, and ensure safety within the home is essential to a single parent of two young children.

Ensures smooth transition between ambulatory or acute care and home health care or other types of health care in community settings

Continuity of Care

Long term care facilities examples

Convalescent home, Home healthcare, hospice, nursing home

A successful discharge includes effective planning. Identifying and meeting client needs beyond the acute care facility reduce readmissions. Which nursing role is of great importance to this success?

Coordinator The discharge planner or coordinator is the health or social services professional who is responsible for coordinating the transition and serving as a link between the discharging facility and the community

A nurse is caring for a 17-year-old pregnant client who is unable to afford health care. Which action will the nurse perform to obtain assistance for this client?

Create a referral to the social work department

In anticipation of discharge, a nurse is teaching the daughter of an older adult client how to change the dressing on the client's venous ulcer. Which teaching strategy is most likely to be effective?

Demonstrate and explain the procedure and then have the daughter perform it.

The nurse is working with a client's family and social worker to select a home health care agency. Which question does the nurse state should be the family's priority when interviewing potential home health agencies?

Does the agency meet uniform standards for licensing, certification, and accreditation by state agencies and/or federal programs?

Socioeconomic needs

Employment, crime/neighborhood safety, housing/homelessness, education, food environment

In same-day surgery clinics, screening tests and teaching take place upon admission to the clinic.

False In same-day surgery clinics, screening tests and teaching take place prior to admission to the clinic.

Current illness Current medications Prior illness, chronic illnesses Surgeries Previous Hospitalizations Other relevant data

Health History

The nurse is planning discharge of the client who had surgery for a left hip replacement. The client is being discharged from the hospital to the home and requires home medical services. Which item would be provided by home medical services?

High-rise toilet seat

ISBARQ Method of Patient Hand-off

I - Introduction S - Situation B - Background A - Assessment R - Recommendation Q - Question and answer

Aim of care coordination

Link patients with resources in the community to enhance their well-being Improve information exchange Reduce fragmentation and duplication of services

Which type of home healthcare agency is a local health department?

Official or public agency

Ambulatory Care Centers:

Outpatient Medical Care May be located in hospitals or freestanding Walk in services, so no appointment necessary, Usually opened past traditional hours These include diagnostic services, minor surgical procedures, and consultations

Leaving AMA (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.

Which measure should a home health care nurse integrate into routine practice to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation

Prior to the discharge of a client who is recovering from a stroke from an acute care facility, the nursing case manager has the nursing staff, client, client's family, physical therapist, and home health nurse meet. The nurse will identify what purpose for this meeting?

Prepare the client to receive home care.

The nurse is admitting a client for outpatient surgery. When the nurse asks what the client has been told about self-care following discharge, the client says, "No one has told me anything." Which nursing intervention is indicated?

Provide the teaching.

Psychosocial Assessment

Provides additional information from which to develop a plan of care. Alcohol, Tobacco, Recreational drugs, and caffeine use

A client with severe congestive heart failure (CHF) has been referred to a long-term care facility. The nurse is transferring care from the hospital setting to a long-term care facility. Which action is a priority to ensure continuity of care for this client?

Providing accurate and complete communication to the new facility

Hospitals provide

Providing acute and specialized care. Equipped for complex and emergency procedures. Inpatient and outpatient services.

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

Providing client education

SBAR communication

R stands for recommendations (identification of pending lab results and what needs to be done over the next few hours, along with other recommendations for care).

SBAR

S stands for the situation (complaint, diagnosis, treatment plan, and client's wants and needs);

One of the fastest growing venues of practice for the nurse is home health care. What is the basis for the growth in this health care setting?

The discharge home of clients who are more critically ill

The home health nurse is conducting a home safety assessment during the admission of a homebound client. Which factors should the nurse be sure to assess for? Select all that apply

The feasibility of modifying the home The home's safety against home invasions The presence of indoor plumbing The presence of pest infestations

A nurse is using the ISBARQ (introduction, situation, background, assessment, recommendation, and question and answer) framework for handoff communication. Which examples accurately represent this process? Select all that apply.

The individuals involved in the process identify themselves, their roles, and their jobs. The nurse reports the client's vital signs, mental and code status, medications, and lab results The nurse explains the client's chief complaint, diagnosis, treatment plan, and wants/needs. The nurse reports the current provider's assessment of the client and need for further services.

Indications for transfer and discharge

The level of health care changed, another setting is required to provide necessary care, the facility does not offer the type of care a client now requires or the client no longer needs inpatient care & is ready to return home.

Which statement 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

Physician's Offices

These are settings for primary care and routine medical consultations. Services include health check-ups, treatment of minor illnesses, and management of chronic conditions

Long term care facilities

These provide extended care for patients needing long-term medical support, such as the elderly, those with chronic illnesses, or patients in rehabilitation. A resident in a long-term care facility might receive comprehensive geriatric care, including medication management and physical therapy.

Nurses use standard hand-off communication tools ISBAR to facilitate

Transfers and discharges

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.

True

Home health care services are delivered to persons at home who are recovering from illness, are disabled, or are chronically or terminally ill and need various services to progress, maintain function, or perform their activities of daily living (ADLs).

True

SBAR provides a framework for communication between members of the health care team about a client's condition. It is an easy and focused way to set expectations for what will be communicated between members of the team, which is essential for developing teamwork and fostering a culture of client safety.

True

The need for thorough documentation is especially high in home health care settings, both to ensure continuity of care and to provide a legally acceptable record of what occurred during nurse-client interactions.

True

To ensure continuity of care for the client, the nurse should send a detailed assessment and care plan from the hospital to the extended care facility. Frequently, the nurse at the hospital provides a verbal report to the nurse at the new facility using the approved handoff technique.

True

Which are examples of factors the nurse would assess to determine a client's functional abilities? Select all that apply.

Whether the client wears eyeglasses The client's ability to ambulate The client's comprehension

Objective data

are information that the nurse can gather through direct assessment, including what can be seen, heard, felt, or measured. These include vital signs, height, weight, and findings on palpation of the abdomen.

Health departments

are public agencies supported through tax dollars and benefit the community in which they are located

Subjective data

are those that the client reports or describes, such as marital status, occupation, smoking and alcohol history, and a list of medications.

Discharge planninf starts

at admission

Direct health needs

behavioral health/ substance use, mental health, chronic diseases, uninsured or underinsured; dental services

Which client should the community health nurse monitor most closely for fragmentation of care

client with complex psychosocial and medical needs, requiring several specialists

Nurse navigator

clinically trained nurse responsible for the identification and removal of barriers to timely and appropriate treatment

The initial step in discharge planning is

collecting and organizing data about the client, as this provides information on the client's health care needs.

Discharge education

discuss discharge instructions and provide a copy to client, instructions should be clear, concise language that the client will understand.

Home medical services provide

durable medical equipment, such as walkers, canes, crutches, wheelchairs, high-rise toilet seats, commodes, beds, and oxygen

when do nurses establish the ability of the clients

during admission assessment

A 16-year-old client has been injured in an accident and is receiving home care due to fractures and multiple trauma-related injuries. The client states, "I do not know why I survived and not my best friend." The nurse should prioritize what action?

encouraging the client to communicate these feelings to family and friends The home health care nurse can assist in coordinating care needs and encouraging family, teachers, schoolmates, and friends to understand the client's struggles and help support the client's needs.

A home health care nurse develops a client's individualized plan of care during the:

entry phase.

The nurse is caring for a client who would benefit from home health care services. In preparing for discharge, the nurse is aware that home health care can only be initiated if the:

health care provider writes an order for home care

Custodial services include

homemaking and housekeeping services, as well as companionship and live-in services

A caregiver

is a family member or paid helper who regularly looks after a child or a person who is sick, older, or disabled

case-based approach

is used when the nurse manager assigns tasks based on the client's diagnosis

convenience of telehealth

limits risk of exposure to illnesses; shorter wait times; increased access

Functional nursing

method of care that involves assigning specific tasks to each team member such as medication administration or wound care

During the pre-entry phase

which includes the referral process, the provider or discharge planner of a hospital contacts the home care facility and provides a brief medical history, along with indications for home health services, and then the referral nurse at the home care facility collects as much information as possible about the client's diagnoses, surgical experience, socioeconomic status, and treatments ordered.

Healthy People 2030

will promote a holistic approach to health promotion and disease prevention