Chapter 12 - Interprofessional Collaborative Practice and Care Coordination Across Settings

Community-Based Health Care

Provided to people who live within a defined geographic area.

Continuity of Care

Ensures smooth transition between ambulatory or acute care and home health care or other types of health care in community settings.

Qualities of the Community-Based Nurse

Knowledgeable and skilled, independent in making decisions, accountable.

Roles of the Community-Based Nurse

Patient advocate, coordinator of services, patient and family educator.

Patient Advocate

The protection and support of another's rights.

SBAR

A communication framework that stands for Situation, Background, Assessment, Recommendation.

ISBARQ

An extension of SBAR that includes Question and answer.

SBAR Scenario #1

RN calling provider regarding patient's elevated temperature, breathing difficulties, and deteriorating condition.

Patient's Elevated Temperature

Jeff's temperature this evening shot up to 103°C.

Respiratory Rate (RR)

RR of 40.

Heart Rate (HR)

HR of 95 BPM.

Oxygen Saturation (O2 Sat)

O2 Sat of 82% on room air.

Patient Condition

He is pale and also drooling.

Background for SBAR

Jeff was transferred 2 days ago from the state home for children with respiratory difficulties.

Laura's Situation

Laura, a 78 year old woman, has been caring for her sister Ellen at home.

Alzheimer's Disease

Ellen was diagnosed with Alzheimer's disease 2 years ago.

Home Care Referral

The nurse would work with Laura to determine her needs and possibly ask social services for assistance with a referral to home care.

Community Services

Resources and community services that may assist Laura.

Patient Complexity

Laura is unsure if she can care for her sister by herself due to increased complexity of care.

Nurse's Role

The nurse would assist Laura in determining her needs.

Patient Satisfaction

Now they are happy.

Situation (S)

The current status or condition of the patient, including any immediate concerns.

Background (B)

Relevant medical history and context of the patient's condition.

Assessment (A)

The nurse's evaluation of the patient's condition and any changes observed.

Recommendation (R)

Suggestions for further action or intervention needed for the patient.

PRN morphine sulfate

A medication prescribed to be taken as needed for pain management.

End-stage breast cancer

The final stage of breast cancer where the disease is advanced and typically not curable.

Home hospice care

Supportive care provided to patients in the final phase of a terminal illness, focusing on comfort and quality of life.

Palliative care

Specialized medical care focused on providing relief from symptoms and stress of a serious illness.

Total knee replacement

A surgical procedure in which a damaged knee joint is replaced with an artificial joint.

ISBARQ framework

A structured method for communication during patient handoffs, including Introduction, Situation, Background, Assessment, Recommendation, and Questions.

Analgesics

Medications used to relieve pain.

Ambulating

The act of walking or moving from one place to another.

Frail

Physically weak or delicate, often due to age or illness.

Patient handoff

The transfer of patient information and responsibility from one healthcare provider to another.

Visiting nurses

Nurses who provide care to patients in their homes.

Caregiver

A person who provides care for another, often a family member or friend.

Discharge papers

Documents that authorize a patient's release from a healthcare facility.

Comfort level

A patient's state of physical and emotional well-being.

Moaning

A low sound made by a person in pain or discomfort.

Grimacing

A facial expression indicating pain or discomfort.

Overwhelmed

Feeling unable to cope due to excessive demands or stress.

Interprofessional Collaborative Practice

Defined as what happens when multiple health workers from different professional backgrounds work together with patients, families, carers, and communities to deliver the highest quality of care (WHO, 2010). The goal is to deliberatively work together to build a safer and better patient-centered and community/population-oriented U.S. health care system.

Care Coordination

Central responsibility of all health care professionals, and especially nurses. Aim: Link patients with resources in the community to enhance their well-being, improve information exchange, reduce fragmentation and duplication of services, and ensure that patients get the right care at the right time in the most efficient and cost-effective manner, by the right person in the right setting.

Care transition

A continuous process in which a patient's care shifts from being provided in one setting of care to another.

Nurse navigator

Identifies and removes barriers to treatment, is a clinically trained nurse, and serves as the central point of contact for patient care.

Patient navigator

A nurse, social worker, or lay person who focuses on the support aspects of care.

Vulnerable Populations

People with disabilities or multiple chronic conditions, people with mental illnesses or substance use, cultural, racial, and ethnic minorities, people experiencing poverty in rural and urban areas, those who are homeless, and undocumented immigrants.

Admission to Ambulatory Care Setting

Patient receives health care services but does not remain overnight. In most offices and clinics, patients complete a short health history. In same-day surgery facilities, screening tests, teaching, and admission take place before patients enter the setting.

Admission to the Hospital

Preparing the room for admission, admitting the patient to the unit, and completing medication reconciliation to ensure that all medications have been correctly ordered or discontinued.

Information Obtained on the Admission Sheet

Includes name, address, and date of birth of patient, gender and marital status, name of admitting physician, name of nearest relative, occupation and employer, financial status for health care payment, religious preference, date and time of admission/admitting diagnosis, and identification number.

Question #2

Tell whether the following statement is true or false: In same-day surgery clinics, screening tests and teaching take place upon admission to the clinic.

Answer to Question #2

Answer: B.

Transfer within the hospital

Movement of patients from one department or unit to another within the same hospital.

Transfer to an extended care facility

Movement of patients from a hospital to a facility that provides long-term care.

Discharge Planning

A process that begins on admission, assessing patient needs and coordinating care for a safe transition.

Essential Components of Discharge Planning

Includes assessing strengths and limitations, implementing care plans, and evaluating effectiveness.

Criteria for Formal Discharge Plan and Referrals

Factors such as lack of knowledge, social isolation, chronic disease, major surgery, and financial difficulties that necessitate a formal discharge plan.

Leaving AMA - Against Medical Advice

A situation where a patient chooses to leave the hospital against the advice of their healthcare provider.

Patient's Rights When Leaving AMA

Patients must sign a release form, be informed of risks, and have their signature witnessed.

Telehealth

The use of electronic information and telecommunication technologies to provide care remotely.

Home Health Care Services

Includes high-technology services, skilled professional services, custodial services, hospice services, and community support services.

Concepts of Home Health Care

Involves patients and family caregivers, referrals for home care, safety considerations, and legal considerations.

Assess strengths and limitations

Evaluating the capabilities and challenges faced by the patient, family, or support person.

Assess the environment

Evaluating the patient's living situation and support systems.

Implement and coordinate the care plan

Putting into action the agreed-upon strategies for patient care.

Consider individual, family, and community resources

Taking into account available support systems and resources for the patient.

Evaluate effectiveness of care

Assessing whether the care provided meets the patient's needs and goals.

Planning for discharge

The process that starts upon admission, collecting and documenting patient information.

Social isolation

A condition that may necessitate a formal discharge plan due to lack of social support.

Recently diagnosed chronic disease

A factor that may require a formal discharge plan due to ongoing care needs.

Major surgery

A condition that may necessitate a formal discharge plan for recovery support.

Prolonged recuperation

A situation that may require a formal discharge plan due to extended recovery time.

Emotional or mental instability

A condition that may require a formal discharge plan to ensure proper support.

Complex home health care regimen

A situation that may necessitate a formal discharge plan due to intricate care requirements.

Financial difficulties

A factor that may require a formal discharge plan to address potential barriers to care.

Terminal illness

A condition that may necessitate a formal discharge plan for end-of-life care considerations.