INTERPROFESSIONAL COLLABORATIVE PRACTICE & CARE COORDINATION

What is Community Health?

Focuses on promoting overall health and preventing disease within populations.
Example: Programs that reduce smoking or promote blood pressure screening.

What are “Living Healthy Indicators (LHI)” examples?

• ↑ People with health insurance

• ↑ Adults screened for colorectal cancer

• ↓ Food insecurity

• ↓ Adult smoking

• ↓ Maternal & infant deaths

• ↑ BP control in adults
  Example: Free community BP screening event.

What questions should community nurses ask about their community?

• Top 3 health issues?

• Top 3 unhealthy behaviors?

• Top 3 factors impacting well-being?
  Example: Obesity, smoking, and lack of access to care.

What is Community-Based Care?

• Focuses on patients with acute or chronic problems.

• Care provided wherever patients are (home, school, work, church).

• Nurse must adapt to patient’s environment.
  Example: Home health nurse monitoring diabetic patient at home.

Qualities of a Community-Based Nurse

• Knowledgeable & skilled (communication, clinical).

• Independent decision-maker.

• Accountable (no “next shift” to follow up).
  Example: RN making medication adjustments independently in home care.

What is Continuity of Care?

• Uninterrupted, consistent care across settings.

• Ensures smooth transition between hospitals, rehab, home, etc.
  Example: Discharge plan + follow-up home visit.

What is TeamSTEPPS and ISBAR?

• TeamSTEPPS: Tools to improve team communication & safety.

• ISBAR: Identify, Situation, Background, Assessment, Recommendation — used for patient handoffs.
  Example: “I’m the nurse calling about Mr. Lee (Identify)... his BP dropped (Situation)...”

What is the CUS Communication Tool?

Used to express safety concerns:

• C – Concerned

• U – Uncomfortable

• S – Safety issue
  Example: “I’m Concerned about his breathing, Uncomfortable with this rate, this is a Safety issue.”

What is Interprofessional Collaborative Practice?

• Multiple health professionals work with patients/families to deliver high-quality, patient-centered care.

• Goal: safer, coordinated, and efficient system.
  Example: Nurse, PT, and dietitian planning care for stroke patient together.

What makes a successful healthcare team?

• Work interdependently, adaptively.

• Have complementary skills.

• Effective leadership, clear roles, accountability.

• Work toward a common goal.
  Example: Code team responding to cardiac arrest with defined roles.

Teamwork in Action — How it’s Done

• Safety huddles: 10-min start of shift meeting.

• Patient rounds: share info.

• Safety rounds: done in pairs.

• Daily goal sheets: 1–2 daily patient targets.

• Structured family meetings & shared care plans in EHR.
  Example: Morning huddle updates unit goals and safety risks.

What is a Care Coordinator?

• Organizes patient’s care between providers and services.

• Ensures smooth transitions, communication, and follow-up.
  Example: RN coordinating discharge meds and home health orders.

Populations with Special Care Coordination

• People with disabilities or mental illness

• Minorities (cultural/racial/ethnic)

• People in poverty (rural or urban)

• Undocumented immigrants
  Example: RN arranges interpreter services for non-English speaker.

Transfers Between Settings

• Patients need a formal discharge plan and referral to the next facility.

• Key for continuity of care and preventing readmission.
  Example: Sending stroke patient from hospital to rehab with med list and summary.

Leaving the Hospital AMA (Against Medical Advice)

• Most adults can leave AMA (except some mental health cases).

• Does not cancel insurance, but may increase costs if readmitted.

• Patient signs or writes refusal letter for record.
  Example: Patient signs AMA form after refusing treatment.

What is Telehealth?

• Care delivered via phone or video remotely.

• Allows chatting, messaging, or remote patient monitoring.
  Example: Video call follow-up for medication adjustment.

Types of Care Provided via Telehealth

• Wellness visits, prescriptions, eye exams

• Nutrition & mental health counseling

• Urgent care for sinusitis, rash, UTI, back pain
  Example: Nurse practitioner treats rash over video visit.

What is Home Health Care Nursing?

• Patients discharged quicker and sicker → home nurses essential.

• RN responsible for care coordination.

• Requires provider order and approved treatment plan from primary caregiver.
  Example: Home RN changing wound dressing for surgical patient.

Home Safety Responsibilities

• Assess home for fire, fall, poisoning hazards.

• Check neighborhood safety before first visit.

• Keep vehicle reliable, don’t carry valuables.

• Notify facility of travel plans.

• Stay alert in all environments.
  Example: Remove loose rugs to prevent fall during home visit.