Chapter 12 - Interprofessional Collaborative Practice and Care Coordination Across Settings

Care of patients within and across healthcare settings

Community health

Community based

Continuity

Collaborative

Care coordination

Healthy People 2030

Leading health indicators

John Hopkins Assessment

Socioeconomic needs - Employment, safety, housing, education, food

Direct needs - Behavioral health, mental health, chronic diseases, uninsured or underinsured, dental

Community based health care

Provided within a defined geographic area

Continuity of care when patient moves levels or settings

Interventions

Manage acute or chronic illness

Promote self care

Community based nurse qualities

Knowledgeable and skilled

Independent decision making

Accountable

Community based nurse roles

Advocate

Coordinator of services

Patient and family educator

Continuity of care

Smooth transition

Patient handoffs - SBAR or ISBARQ

ISBARG

Introduction

Situation

Background

Assessment

Recommendation

Question and answer

Core competencies for interprofessional collaborative practice

Values/ethics

Roles and responsibilities

Communication

Teams and teamwork

Care coordination

Care transition - Patient’s care shifts from being provided in one setting of care to another

Aim - Link patients within resources to enhance their well being, improve information exchange, reduce fragmentation, and duplication of services

Nurse navigator

Removes barrier to treatment

Clinically trained

Central point of contact

Patient navigator

Nurse social worker

Focuses on support aspects of care

Complexities of care coordination - Vulnerable populations

People with disabilities or multiple chronic conditions

Mental illnesses or substance abuse

Homeless

Cultural, racial, and ethnic minorities

Poverty in rural and urban areas

Undocumented immigrants

Care coordination - Patient Transitions through HealthCare Services

Admissions - Hospital, ambulatory care

Transfers - Withing hospital, to extended care facilities

Telehealth

Use of electronic information and telecommunication technologies to provide care remotely

Wellness visits, prescriptions, dermatologic, eye exams, nutrition counseling, mental health counseling, urgent care conditions

Convenient, limits risk of exposure to illnesses, shorter wait times, increased access

Home health care

High technology services, skilled professional services, custodial, hospice, home medical, community support

Patients and family care givers, referrals, safety, infection prevention, reimbursement sources, legal considerations