FOUNDATION: client- centered care coordination

client- centered care coordination definition

A set of activities purposefully organized by a team of personnel that includes the patient to facilitate the appropriate delivery of necessary services and information to support optimal health and care across settings and over time

client- centered care coordination antecedents

• Client (patient, family, community) requiring multiple services

• Interaction of client with multiple healthcare team members and/or organizations, partnership

• Communication among all entities

• Functioning structures with focused mission/scope of care delivery

• Effective processes to ensure smooth care transitions among entities

client- centered care coordination defining characteristics

• Interorganizational & Interprofessional team that includes the patient

• Communication & information exchange

• Proactive plan of care with goals

• Targeted set of purposeful activities

• Proactive follow-up

Positive or Desired Consequences

Efficient, optimal care coordination

• Goals developed with client input

• Multiple needs of client met (needs within community and/or healthcare providers/organizations)

• Positive communication, trust among team members

• Improved client outcomes (physical, social, psychological, etc.)

• Consistent monitoring of outcomes and implementation of quality improvement processes

• Proactive, focuses on patient wellness

• Appropriate use of resources to save money for patient

risk factors

• Lack of process

• Lack of resources

Negative Consequences

• Reactive, fragmented care

• Mismanagement of resources

• Lack of communication among client and team members – client is ill informed

• Lack of trust, uncertainty – client does not trust team members or system

• Unmet patient/family needs

• Redundant, Ineffective, Duplicative Care

nursing is the

• protection, promotion, and optimization of health and abilities,

• prevention of illness and injury,

• facilitation of healing,

• alleviation of suffering through the diagnosis and treatment of human response

• advocacy in the care of individuals, families, groups, communities, and populations.

purpose of client centered care

to enhance health states, functional abilities, & quality-of-life for individuals, families, and populations

• it is client- centered

• Intra-and interdisciplinary (interprofessional)

care management is

a process

• “systematic series of actions directed at some end”

• “Action of going forward”

what is care coordination focused on

optimizing patient outcomes and care

care management process is a

Framework that Creighton University College of Nursing uses to help students learn to think and make decisions about nursing practice.

Care Management Process Model is…

outcomes oriented

• where do we want to be and how we get there

Why is being ‘Outcomes-oriented’ important?

it gives you the roadmap of where you're going to go and how are we going to get there. it involoves evidence based practice to provide safe care and quality care as well

in the Care Management Process Model nurses…

collaborate with patients, families, communities, & other professionals serve as:

• managers of care, change agents, and advocates for outcomes improvement

Care Management Process Components

• Population Identification

• Expected or Desired Outcomes Identification & Prioritization

• Assessment

• Variance Identification

• Interventions/Strategies

• Evaluation of Care & Outcomes

• Modification

when Identifying & Describing Population we think

abut a group of people not an individual

population profile

a brief and concise paragraph that describes the relationship of a health alteration or disease to the specific population affected

what does the population profile serve as

the foundation for the development of interventions at the health promotion and health protection levels of care delivery by the care manger

Determine Expected Outcomes means finding

Commonly expected end-points or desired responses

determining expected outcomes should be

evidence based and specific to an individual or to a population (depending on who you are serving)

Determine Expected Outcomes: SMART MODEL

is the end goal/ expected outcome

• Specific

• Measurable

• Achievable

• Relevant (to clients current condition)

• Time-specific (can be acheived by end of shift)

what do you do after after identifying the expected outcomes,

assess your client, family, group, or community in order to determine the status of your client in relation to the expected outcomes

what to think about in further assessment

What do you need to know about the issue and the population in relation to the issue/need/disease?

what does knowledge of the population and the issue/need/disease helps determine

which assessments are needed and what information or data are more important

variance

any deviation from the expected

how to identify variances/ cues

after analyze assessment data ask:

• How does what I see/found VARY from the desired outcome?

• What is standing in the way of achieving thedesired outcome?

• Why are these occurring?

• how to get client from variance to expected outcome

intervention is

Outcome-oriented action steps

what to ask during intervention

What actions/strategies should be taken address, remove, or reduce the variances and hopefully achieve the desired outcome?

• These can be actual interventions and/or ongoing assessments

questions to ask to Evaluate Strategies & Outcomes

• Did person/population achieve the desired outcome?

• If not, why? Is it…

• Client-related?- something client did

• Care-related?- something nurse did

• System-related?- resources or insurance

• Are the outcomes realistic? Should they be changed?

questions to ask when Modifying Care Management Process

• What changes should be made to the desired outcomes or to the care management strategies/process to help the person/population achieve optimal outcomes??

• What else should be done?

• What should be done next?

what does care management focus on

the individual client, family, group, or community in the context of the disease

what is the focus of Nursing and of Care Management.

human responses

How does a Care Management Process Model promote Safety & Quality?

uses evidence based practice interventions and assessments

what is the nurses role in care management

be and advocate for client

to start care management process

put interventions and assessments in place