CARE: Client centered care coordination

what is CUCON’s Care Management Process

-A model that helps develop critical thinking

-a way to conceptualize patient care and client health

-Provide safe and quality care to our patients

aspects of CUCON care management process

– Outcomes are integral to this model and goal oriented

– Client and Population focused

– Across the continuum of care

– Collaborative (involves interprofessional team

– Evolving and dynamic (enhacing health states, function abilities, and quality of life for familes, individual, and population)

– Responsive to the demands of current health care climate (can adjust our care)

continuum of care delivery

the top three are always changing and will change to meet the goal

Health Promotion

Before disease or disease symptoms are evident

what is health promotion considered

primary prevention

aspects of health promotion

– Lifestyle and behavior changes

— focused on postive changes of lifestyle and behavior

– Formal or informal educational approaches to make lifestyle choices

• Smoking cessation classes

• Weight loss/diet education programs

• Exercise programs

• Safety education

health protection

• Disease or disease symptoms may or may not be evident at this point

• Strategies physically invasive but still protective in nature (prevent or protect)

• primary or secondary prevention depending on disease

health protection examples

– Immunizations

– Fluoride Water Treatment

– Use of protective clothing/equipment in the work setting

– Screenings (Diabetic, school screenings, etc.)

health restoration

• Disease/dysfunction symptoms are evident

• To restore client from symptomatic to an asymptomatic state

health restoration examples

– Acute care, primary care, or home health setting

– Surgery, wound care, dialysis, diabetic teaching, fluid/medication therapy

health maintenance

• Acute pathophysiological disruptions resolved

• Chronic disease symptoms may be evident but are controlled

what is the aim of health maintenance

to maintain client in optimally functional and relatively symptom-free state

examples of health maintenance

• Cardiac rehabilitation/exercise program

• Prescribed diabetic care regimen adherence

• Learning how to manage one’s disease

population profile contents

– Demographics

– Incidence

– Prevalence

– Risk Factors

– Protective factors

– Morbidity

– Mortality

– Access to care

– Developmental construct (Ericksons)

significance of population profile

Foundation to establish the expected individual client outcomes

sources for population profile

Textbooks, journals, gov’t publications

expected outcomes are…

• Population based

• Desired responses to treatment

• Anticipated disease course along the continuum

• Considered by health state

expected outcomes categories

– Clinical related (Symptom relief)

– Quality related (ADLs, Functional Health State)

– Cost related (Financial)

client profile

What does your client look like when measured against the population based outcomes?

what do considered looking at the client profile

– Consider the patient profile

– Consider the physical assessment up to this point

– Consider assessment categories

assessment categories

• Health

• Diagnostic Tests

• Personal values, beliefs, thoughts, emotions, behaviors

• Functional (ADL’s and IADL’s)

• Family/Social Support

• Environmental

• Resources

• head to toe assessments

how to determine client variance

find out what is the individual’s deviation from the expected population profile?

client findings are

the basis for determining nursing diagnosis and individiual client outcomes

nursing diagnosis is a

way to identify patient problems on which nursing has an impact – not medical diagnoses

NANDA: Actual nursing diagnoses (problem focused) and Health promotion

PES statement

PES statement

Problem, Etiology, Signs/symptoms(defining characteristics)

NANDA: Risk nursing diagnosis

Potential or “risk for” diagnoses- there is no etiology

• Still state “P” problem statement= follow by “as evidence by” and list the risk factors (No signs or symptoms

NANDA: syndrome

clusters of nursing diagnoses that occur together

SMART outcome

• Specific

• Measurable

• Achievable

• Realistic

• Time-sensitive

assessments

• “Gather Data”

• Identify pertinent assessments that will facilitate reaching the expected “SMART” outcome

• Consider the Assessment Categories

• Consider a Standardized Tool

interventions are directed at

individualized client outcomes

what should the intervention correlate to

the assessment data of client

intervention should be

• Patient appropriate

• Supported by the nursing body of knowledge

• Intervention categories

• Designation on care continuum

• Promotion

• Protection

• Restoration

• Maintenance

Care management collaboration examples

• Nurse consultations

• Multidisciplinary consultations

• Community organizations

• Legislative/policy considerations/contacts

Variance Analysis/Evaluation

Were individualized client outcomes met?

if not why not?

reasons why the clients outcomes might not have been met

– Client-related factors (patient refused)

– Care-related factors( meds not administration timely)

– System-related factors (pharmacy didnt have med, etc)

questions to ask during the evaulation

• Does care need to be modified to help achieve individualized client outcomes?

• Were outcomes realistic?

Creighton's Care Management Model Process Tool

• A client-centered and intra- and interdisciplinary process to enhance health states, functional abilities, and quality of life for individuals, families, and populations.

• The process allows clinical and critical thinking with the use of evidence base.

• Is a seamless transition between the care-providers.

• The foci of nursing care management are to assess health states and plan, provide, negotiate, coordinate and evaluate options and services to achieve clinical, quality, cost-effective outcomes.

• This process occurs in a climate of partnership with individuals, families, groups, communities, providers and payers.

• Nurses serve as change agents and advocates for outcomes improvement by seeking solutions that empower clients to promote, protect, restore and maintain health.