Interprofessional Collaborative Practice and Care Coordination

Healthy People 2030

National health objectives to improve population health.

Community Health Needs Assessment

Evaluation of community health requirements and resources.

Socioeconomic needs

Factors affecting health: employment, safety, housing, education.

Direct health needs

Immediate health concerns like mental health and chronic diseases.

Community-Based Health Care

Health services for individuals in specific geographic areas.

Continuity of Care

Seamless transition between different healthcare settings.

Qualities of Community-Based Nurse

Knowledgeable, independent, and accountable in decision-making.

Patient Advocate

Nurse role supporting patient rights and needs.

Coordinator of Services

Nurse role organizing healthcare services for patients.

Patient and Family Educator

Nurse role teaching health information to patients and families.

SBAR

Communication framework: Situation, Background, Assessment, Recommendation.

ISBARQ

Enhanced SBAR including Question for clarification.

Introduction in ISBARQ

First step: introducing the patient and caregivers.

Situation in ISBARQ

Current status and issues regarding the patient.

Background in ISBARQ

Patient history relevant to current care.

Assessment in ISBARQ

Current clinical findings and vital signs.

Recommendation in ISBARQ

Suggested actions or interventions for patient care.

Question in ISBARQ

Opportunity for clarifying doubts or concerns.

Patient Handoff

Transfer of patient information between healthcare providers.

Extended-Care Facility

Healthcare setting for patients needing long-term care.

Rationale for ISBARQ

Ensures comprehensive communication during patient transitions.

Care Coordination

Process linking patients to community resources.

Care Transition

Shift of patient care between settings.

Nurse Navigator

Clinically trained nurse facilitating patient care.

Patient Navigator

Support role aiding patients through care.

Vulnerable Populations

Groups at higher risk for health disparities.

Ambulatory Care Setting

Health services without overnight stay.

Medication Reconciliation

Reviewing patient's medications for accuracy.

Admission Sheet

Document containing patient information at admission.

Discharge Planning

Preparing for patient discharge from health care.

Transfer Within Hospital

Moving patients to different units in hospital.

Transfer to Extended Care Facility

Patient relocation to long-term care settings.

Essential Components of Discharge Planning

Key factors for effective patient discharge.

Screening Tests

Assessments conducted before patient admission.

Teaching in Same-Day Surgery

Patient education prior to surgical procedures.

Patient Strengths Assessment

Evaluating patient's capabilities for care.

Family Support Assessment

Evaluating family roles in patient care.

Environmental Assessment

Evaluating patient's living conditions for care.

Care Plan Coordination

Implementing and managing patient care strategies.

Effectiveness Evaluation

Assessing outcomes of the care provided.

Cultural Competence

Understanding and respecting diverse patient backgrounds.

Health Care Fragmentation

Disruption in continuity of patient care services.

Formal Discharge Plan

Structured approach for patient discharge from healthcare.

Referral Sources

Available options for patient care services post-discharge.

Leaving AMA

Patient leaving against medical advice, legally permitted.

Release Form

Document signing to absolve medical responsibility.

Telehealth

Remote healthcare using electronic communication technologies.

Home Health Care

Services provided in a patient's home for recovery.

Chronic Disease

Long-term health condition requiring ongoing management.

Social Isolation

Lack of social contacts impacting mental health.

Emotional Instability

Unstable emotional state affecting patient well-being.

Complex Home Care Regimen

Intricate healthcare tasks requiring skilled assistance.

Financial Difficulties

Economic challenges hindering access to healthcare.

Terminal Illness

Disease expected to lead to death within time frame.

Health Care Needs Assessment

Evaluation of patient requirements for effective care.

Patient Education

Teaching patients about their health and treatment.

Home Health Care Referrals

Recommendations for services to assist at home.

Discharge Planning Effectiveness

Evaluation of the success of discharge strategies.

Witnessed Signature

Required validation of patient consent on forms.

Risks of Leaving AMA

Potential complications from departing against medical advice.

Wellness Visits

Routine health check-ups to maintain well-being.

Skilled Professional Services

Care provided by licensed healthcare professionals.

Community Support Services

Local resources aiding patient recovery and support.

Self-knowledge

Understanding one's own identity and attributes.

Self-expectation

Desire to become a certain person or achieve goals.

Self-evaluation

Assessment of one's own worth and abilities.

Self-actualization

Realizing one's full potential and capabilities.

Self-esteem

Feeling good about oneself and self-worth.

Self-concept

Mental image or perception of oneself.

Esteem needs

Desire for respect, recognition, and appreciation.

Significance

Feeling valued and important to others.

Competence

Belief in one's ability to achieve tasks.

Virtue

Belief in one's moral integrity and ethics.

Power

Ability to influence or control one's environment.

Ideal self

The person one aspires to become.

Pride

Positive feeling from favorable self-evaluation.

Guilt

Negative feeling from actions conflicting with ideals.

Shame

Feeling of low self-worth and inadequacy.

Formation of self-concept

Development of self-image through experiences.

Internalization

Adopting others' attitudes and societal standards.

False self

Persona created to meet others' expectations.

Maslow's esteem needs

Includes strength, achievement, and independence.

Coopersmith's bases

Foundations of self-esteem: significance, competence, virtue, power.

Self-Awareness

Recognized in infancy; initial self-perception stage.

Self-Recognition

Occurs around 18 months; identifying oneself.

Self-Definition

Defined at age 3; understanding personal traits.

Self-Concept Formation

Develops over time, not innate at birth.

Developmental Considerations

Age-related factors influencing self-concept.

Cultural Influence

Cultural background shapes self-perception and identity.

Internal Resources

Personal strengths and attributes affecting self-view.

External Resources

Support systems impacting self-concept development.

History of Success

Past achievements boost self-esteem and identity.

Crisis Impact

Life stressors can alter self-concept significantly.

Aging Effects

Changes in self-concept due to aging or illness.

Personal Identity

Unique characteristics defining an individual.

Body Image

Perception of one's physical appearance.

Role Performance

Effectiveness in fulfilling personal or social roles.

Socialization

Interactions shaping self-esteem through relationships.

Power in Self-Esteem

Control over one's life and decisions.

Nursing Strategies

Methods to help patients identify and reinforce strengths.