Module 10: Patient care coordination and education

Team based care

partnership between provider and patients (communication along all parts of team)

• Patient centered medical home

• accountable care organization

both models have patient as the focus with all members of team working to provide best outcome for patient.

Patient centered medical home care delivery model (PCMH)

coordinates patient treatment through primary care provider

centralized setting that facilitates partnerships

Five core functions of PCMH

Comprehensive care: care for patient’s needs (whole patient) not just certain medical/physical concerns

Patient centered care: patients and families are the core members of the team

coordinated care: provider directed medical practice with good communication through things like EHR

Accessible services: tools provided through patient information and web portals

quality and safety commitments: delivering quality health care

Accountable care organizations

made of providers associated with defined patient population

voluntarily coordinates care for defined patient population, instead of paying for volume of services it shifts to paying for value of care delivered

Primary care provider

first provider from whom a patient will seek care and services

role: coordinate preventative health care checkups

Specialist

provider that diagnoses or treats conditions that require a specific area of expertise and knowledge

Physician Assistant (PA)

similar training to physicians and are licensed to practice medicine as long as MD/DO supervises them

Advance Practice Nurse (APN)

more education and experience than RN and can perform many same tasks as PA

Registered nurse (RN)

licensed by individuals states and can perform complicated clinical tasks and oversee the case management of patients

Licensed practical nurse

vocational nurses, licensed by individual states

train for 1 year at community college and recieve diploma/AS

Pharmacist

prepare and dispense medications prescribed by provider

must be knowledgeable of individual and various combinations of medicines

Dentist

treat and diagnose issues relating to health of teeth and mouth

Therapist

rehabilitation services

• occupational therapist: assist and educate patients on performing everyday tasks

• physical therapist: asses patient’s pain/strength/mobility and treatment plain to improve

• Speech therapist: work with patients who have had injury, cancer, stroke to regain and maintain ability to communicate, chew, swallow

Psychiatrist

physicians who diagnose, prescribe medications for, and treat mental, behavioral, and emotional disorders

Psychologist

not physicians but have a doctor of psychology (PsyD) or Doctor of philosophy (PhD)

Social worker

assist patients and families in times of transition or crisis

Dietitian

Expert in diet and nutrition

educate patients on connection between chronic disease and nutrition

Support staff

clinic coordinator

medical admin assistant

clinic MA

medical records specialist

Medical billings specialist

financial counselor

scheduler

List of community resources

important to know to benefit patients with certain needs

brochures from organizations are usually free

Depending on specialty CDC has resources that provide services for specific geographic locations

Blood pressure screening

Risk factor: African American race, being overweight, family history, previously recorded high

Breast Cancer

mammogram is x-ray to help identify cancer

recommend that screening starts at age 40

Cervical cancer

pap test used to help identify

recommend every 3 years from 21-29 y/o and every 3-5 years from 30-65 y/o

colorectal cancer

starting at age 45 and can be done by performing fecal occult blood test (FOBT) to detect blood in stool or colonoscopy

Cholesterol screening

adults with family history need to tested more regularly

dental examination

recommended exam and cleaning yearly

Lung cancer

annual lung cancer screening with low dose computed tomography (LDCT) is recommended for adults age 50-80 years who have 20 pack year smoking history and currently smoke or have quit within the past 15 years

bone density

screening for osteoporosis with bone measurement testing in postmenopausal patients younger than 65 years

Diabetes

blood glucose tests are recommended every 3 years or sooner based on medical history

Dilated eye examination

patients with risk of eye disease should have dilated eye exam

risk factor: African American, 40+, and family history of glaucoma

Abdominal aortic aneurysm

recommended one time screening with ultrasonography in male patients 65-75 y/o who have ever smoked

Hep C screening

one time screening for those with risk factors:

risk factors: being born between 1945-1965, history of blood transfusions or organ transplant before 1992, use of injected illegal drugs, and chronic liver disease/HIV/AIDS

HIV

one time screening for adolescents aged 15-65 years

Alcohol use

drinking in moderation:

• female have no more than one drink a day

• male patients have no more than two drinks a day

Nicotine or tobacco use

questions are related to current and past nicotine usage:

• what product, which kind, how much per day, history of use, quitting behaviors

Drug use

Identify any history or recent drug abuse

signs of drug abuse

poor hygiene

change in eating habits or sleep patterns

loss of interest in favorite things

very energetic, talking fast, very sociable

tired, sad, nervous, agitated, bad moods

missing school, work, appointments

spending money excessively

slowed reaction time, paranoid thinking

Intimate partner violence

domestic abuse for all genders, controlling behavior, physical abuse, sexual abuse, emotional/verbal abuse

Older adult safety

how safe older person feels at home, screen for abuse and neglect

depression

several tools can scan for depression most ask questions related to moods, thoughts, and feelings

patient interview

discuss changes in health status

perform medication reconciliation (determine if refills are needed)

confirm allergies

screen for any health conditions (fall risks, mental health status, developmental screening tests)

update health history

educate patient regarding preventative services needed

discuss any needed or recommended immunizations

Clinical quality measures

identify treatments, processes, experiences, outcomes

Transportation and medical equiptment

resource that assists with transportation to and from medical appointments and aids in obtaining needed medical equiptment

Adult day programs

community resource that offers daily activities for older adults

Assistive living

community resource that houses older adults or disabled individuals

provides nursing care, housekeeping, and prepares meals

Long term care

community resource that offers services for individuals who can no longer perform basic daily living activities independantly

educational program and support groups

educate and support individuals with specific needs

Low cost medication programs

community resource that assists low income individuals with obtaining needed medications

Community health programs

community resource that provides programs to promote health and overall well being

Nutrition education

encourage limiting fat intake, eat fruits, veggies, fiber

Heart healthy diet (AHA): limit sugary drinks, sweets, fatty meats, salty/high processed foods

eating foods lower in sodium (less than 2,300 mg of sodium in a day)

Exercise

regular exercise can help patients maintain weight and lower blood pressure or cholesterol

How much exercise is required to lower blood pressure or cholesterol

40 minutes of aerobic exercise of moderate to vigorous intensity three-four times a week

Resources for disabilities

• TASH: advocates for human rights and inclusion for people who have significant disabilities and support needs

• national disability rights network

• specialty designed instruction programs

• American association on intellectual and developmental disabilities

• The arc: develops programs and funds public policy

Who orders referrals for patients to see specialists?

primary care provider

Behavioral barriers to care

decisions regarding diet, exercise, smoking, cessation, avoiding illicit drug use

Biological/genetic barriers to care

sickle cell anemia, hemophillia, cystic fibrosis, heart disease, cancer

environmental barriers to care

opportunities for employment and education, access to fresh foods, exposure to crime and violence, adequate transportation

Physical barriers to care

natural environment on health including weather/climate change, housing, neighborhoods, work sites, recreational settings, exposure to toxic substances

Cultural barriers to care

role in the family or community, views on: health, wellness, dying, death, relationships, beliefs related to foods, diet, illness, health, fertility, childbirth

Which communicable diseases should be reported?

• TB

• E. coli

• foodborne diseases

• Lyme disease

• Hepatitis B, C, D, & E

• human Immunodeficiency virus (HIV)

• Gonococcal infections

• COVID-19

which form of telehealth is a substitute for in-person visits?

Live video

What is the main reason for patient deficiencies during transition of care

lack of communication

Can a medical assistant refer a patient to a resource without the provider’s referral?

Yes, a referral is not needed in formal writing to refer to a rehabilitation (drug addiction) or other community resource