11. Continuity of Care--Community Nursing

community partnerships

Individuals

Families

Community agencies

Civic organizations

Citizen groups educational settings

Political offices

Employment bureaus

characteristics of partnerships

Shared power

Shared goals

Integrity

Flexibility

Negotiation

Groups partnering to elicit needed change in the community are more powerful than a nurse working independently with an individual

consultations

someone who has a specialized knowledge and provides expert advice, services, or information

nursing actions for consultations

Initiate necessary consults

Seek expertise representing a variety of disciplines

Request expert opinions of key community members, agency leaders

Seek expertise of other nurses or advanced practice nurses

Incorporate recommendations from consultant

Coordinate recommendations from multiple consultants

Serve as an expert witness in legal proceeding

Serve as a consultant regarding the health care needs of individuals, families, and groups within the community served

referrals

for individuals in acute care settings typically are based on the medical diagnosis or other relevant clinical information

nurse's role in referrals

Nurse assists in linking client with community resources, and must have knowledge of individuals and organizations. The nurse should also use knowledge of types of assistance the client will accept based on client's personal beliefs and values

The nurse educates clients about community resources and self-care measures

steps in referral process

1) Engaging in a working relationship with the client

2) Establishing criteria for the referral

3) Explore resources

4) Accepting the client's decision to use a given resource

5) Making the referral

6) Facilitating the referral

7) Evaluate outcome

client barriers to referrals

Lack of motivation

Inadequate information about community resources

Inadequate understanding of the need for referral

Accessibility needs

Priorities

Finances

Cultural factors

resource barriers to referrals

Attitudes of health care personnel

Costs of services

Physical accessibility of resources

Time limitations

Limited expertise working with culturally diverse populations

follow-up considerations for referrals

Monitor for completion of referral

Assess whether referral outcomes were met

Determine if the client was satisfied with the referral

discharge planning

an essential component of the continuum of care, and is an ongoing assessment that anticipates the future needs of the client

discharge planning requires...

ongoing communication with the client, nurse, providers, family, and other members

discharge planning goal

enhance well-being of the client by establishing appropriate options for meeting the health care needs of the client

when does discharge planning begin?

admission

case management

Promote interprofessional services and increase client/family involvement

Decrease cost by improving client outcomes

Provide education

Reducing gaps and errors in care

Apply EBP protocols and pathways

Advocate for quality services and client rights

case management nursing

must possess communication skills, ability to articulate the needs of the client to various parties can save time and promote successful outcomes

what do case management nurses face?

dilemmas as they work with consumers and providers to determine the best course of action

case managers are at risk for liability

Care management

Referrals

Experimental treatments

Confidentiality

Fraud and abuse

informatics

combination of nursing science with information and communication technologies in delivery of nursing care

components of informatics

Health records

Healthcare meetings

Billing

Support groups

Orientation

Training

physical/audio/visual data

Outreach tool for education

Laws govern licensing/scope of practice/negligence

Partner with state board to change

NIOSH, NOASH

nurse's role in health policy

Nurses need to know the process/current legislation

Influence through professional communication

Advocacy imperative

Present EBP solutions

change agents

advocate for needed change at the local, state, or federal level

lobbyists

persuade or influence legislators. Individuals or professional nursing associations can participate in the lobbying process

coalitions

facilitation of goal achievement throught the collaboration of two or more groups

public office

serve society and advocate for change by influencing policy development through public service

Affordable Care Act (ACA)

The comprehensive healthcare reform law enacted in March 2010 (sometimes known as the Patient Protection and Affordable Care Act [PPACA], the Health Care and Education Reconciliation Act, or "Obamacare") designed to improve the quality and accessibility of healthcare while reducing its cost

equity

As applied to healthcare, the notion that healthcare does not vary in quality because of gender, race, age, ethnicity, geographic location, or socioeconomic status