Chapter 9: Continuity of Care

Chapter 9: Continuity of Care

Role of Community Health Nurses

• Maintain continuity of care as clients transition from acute → outpatient settings

• Address challenges from chronic disease prevalence (more clients moving in/out of acute care)

• Provide support through community agencies for:

  • Medical needs

  • Financial needs

  • Personal/social needs

• Use technology to coordinate and maintain continuity of care

Community Partnerships

• Essential for improving and maintaining healthy communities

• Nurses should facilitate development of partnerships within the community

• Partnerships enable collaborative health outcomes

Management of Care

Case Management

• Provide discharge information for home or community setting

Client Rights

• Advocate for client rights and needs

Ethical Practice

• Practice according to nursing code of ethics

Referrals

• Identify and connect clients with community resources

Concepts of Management

• Act as liaison between client and others

Performance Improvement (Quality Improvement)

• Define and participate in quality assurance/performance improvement activities

Health Promotion and Maintenance

Self-Care

• Assess client’s ability to manage care at home

• Plan care accordingly

• Consider self-care needs before developing/revising care plan

Community Partnerships

Essential for improving and maintaining healthy communities

Nurses should facilitate development of partnerships within the community

Partnerships enable collaborative health outcomes

Examples of Partnering Entities

• Individuals

• Families

• Community agencies

• Civic organizations

• Citizen groups

• Educational settings

• Political offices

• Employment bureaus

• Faith-based organizations

Characteristics of Successful Partnerships

• Shared power (equal voice among partners)

• Shared goals (common objectives)

• Integrity (honesty and ethical collaboration)

• Flexibility (adaptability to needs/situations)

• Negotiation (problem-solving and compromise)

A nurse is creating partnerships to address health needs within the community. The nurse should be aware that which of the following characteristics must exist for partnerships to be successful?

Select all that apply.

a

Being a leading partner with decision-making authority

b

Flexibility among partners when considering new ideas

c

Adherence of partners to ethical principles

d

Varying goals for the different partners

e

Willingness of partners to negotiate roles

b Flexibility among partners when considering new ideas

c Adherence of partners to ethical principles

e Willingness of partners to negotiate roles

Case Management Continuum of Health Care (Image)

Continuum of Care

• Ensures individualized health services are delivered without disruption

• Nurse helps client transition smoothly between levels of care

Case Management Process (Patient-Centered)

1. Assess – evaluate client needs

2. Plan – develop care strategies

3. Collaborate – coordinate with providers

4. Implement – put plan into action

5. Monitor – track progress and outcomes

6. Evaluate – review effectiveness and adjust as needed

Support Areas in Continuum

• Financial

• Social support

• Ethics & legal considerations

• Advocacy

Community Health Nurse Role

• Provide case management services (supervision, individualized care, follow-up)

• Make referrals to appropriate resources (medical, social, financial, etc.)

• Build ongoing relationships between client and health care providers → improves health outcomes

Consultations

An expert who provides specialized knowledge, advice, services, or information.

Nursing Actions

• Initiate necessary consults, or notify provider so they can initiate.

• Seek expertise from health care professionals in various disciplines.

• Request expert opinions from key community members, agency leaders, and professionals.

• Collaborate with specialty nurses (psychiatric, school, gerontological, diabetes management, etc.) and advanced practice nurses (PMHNP, gerontological NP).

• Incorporate consultant recommendations into the client’s plan of care or community program planning.

• Coordinate recommendations from multiple consultants (providers, APNs, pharmacists, dietitians, therapists, holistic providers) to ensure client safety.

• Serve as expert witness in legal proceedings.

• Act as consultant for the health care needs of individuals, families, and groups in the community.

Referrals

In acute care are usually based on medical diagnosis or clinical information.

Resources help restore, maintain, or promote health.

Nurse responsibilities:

• Link client with appropriate community resources

• Know individuals/organizations that can serve as resources

• Match assistance to client’s personal beliefs and values

• Educate clients about community resources and self-care measures

Health Care Services

Providers

Acute-care settings

Primary care sites

Health departments

Transitional and long-term care facilities

Home care services

Rehabilitation services

Physical therapy services

Occupational therapy services

Pharmacies

Specialty Service Agencies

Support services

Psychological services

Faith community centers

Support groups

Life care planners

Medical equipment providers

Health insurance companies

Meal delivery services

Transportation services

Barriers to the Referral Process

Client

• Lack of motivation

• Inadequate knowledge about resources

• Inadequate understanding of need for referral

• Accessibility needs

• Priorities

• Finances (SDOH)

• Cultural factors (SDOH)

Resource

• Attitudes of health care personnel

• Cost of services (SDOH)

• Physical accessibility of resources

• Time limitations

• Limited expertise with culturally diverse populations (SDOH)

Steps in the Referral Process

1. Engage in a working relationship with the client

2. Establish criteria for referral

3. Explore available resources

4. Accept client’s decision on chosen resource

5. Make the referral

6. Facilitate the referral

7. Evaluate the outcome

Follow-Up Considerations

• Monitor referral completion

• Assess whether outcomes were met

• Determine if client was satisfied with referral

A nurse developing a community health program is determining barriers to community resource referrals. Sort the examples of barriers into client barriers or resource barriers.

Costs associated with services

Decreased motivation

Inadequate knowledge about resources

Limited number of service providers

Lack of interpreters

---

Client barrier

Resource barrier

Client barrier

• Decreased motivation

• Inadequate knowledge about resources

Resource barrier

• Costs associated with services

• Limited number of service providers

• Lack of interpreters

Discharge Planning

Essential part of the continuum of care → anticipates client’s future needs.

Requires ongoing communication among:

• Client

• Nurse

• Providers

• Family

• Interprofessional team

Goal: enhance client well-being by identifying appropriate options for meeting health care needs.

Begins at admission (not just at discharge).

A case management nurse is initiating referrals for a client as part of discharge planning. Place in order the actions the nurse should plan to take.

Provide information about the client to the referral agencies.

Monitor client satisfaction with the referral.

Identify referrals the client needs.

Review available resources with the client.

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1

2

3

4

1 Identify referrals the client needs.

2 Review available resources with the client.

3 Provide information about the client to the referral agencies.

4 Monitor client satisfaction with the referral.

Case Management

Indications/Role

• Used in a variety of health care settings to:

  • Promote interprofessional services & client/family involvement

  • Decrease costs through improved outcomes

  • Provide education for health participation

  • Reduce gaps/errors in care

  • Apply evidence-based protocols & pathways

  • Advocate for quality services and client rights

Collaboration

• Involves clients, families, community resources, payer sources, and health care professionals

• Requires strong communication skills to articulate client needs across systems

• Promotes effective care coordination and successful outcomes

Ethical Challenges

• Nurses may face dilemmas balancing client needs vs. provider/system decisions

Liability Risks in Case Management

1. Care Management – mismanagement: incomplete records, inappropriate delegation, no alternative treatments

2. Referrals – mismanagement: incompetent providers, low-quality/substandard care, poor communication

3. Experimental Treatments – mismanagement: failure to notify client of experimental nature or make timely recommendations

4. Confidentiality – mismanagement: HIPAA violations, sharing protected information

5. Fraud & Abuse – mismanagement: false claims, inaccurate data, billing for unnecessary/substandard care, compensation for referrals/treatments

Nursing Process in Case Management

• Guides assessment, planning, implementation, and evaluation of client’s health care

Scope of Role

• Coordinates care among providers (nursing staff, rehab, OT/PT, home health, community resources)

• Advocates across all aspects of health care system

• Acts proactively: balances client needs, prevents complications, and ensures continuity from acute → community-based care

• Focus on early discharge planning and smooth transition across settings

Liability Risks in Case Management

Care Management – mismanagement: incomplete records, inappropriate delegation, no alternative treatments

Referrals – mismanagement: incompetent providers, low-quality/substandard care, poor communication

Experimental Treatments – mismanagement: failure to notify client of experimental nature or make timely recommendations

Confidentiality – mismanagement: HIPAA violations, sharing protected information

Fraud & Abuse – mismanagement: false claims, inaccurate data, billing for unnecessary/substandard care, compensation for referrals/treatments

A nurse is working with a client who has systemic lupus erythematosus and recently lost their health insurance. Which of the following actions should the nurse take in the implementation phase of the case management process?

a

Coordinating services to meet the client’s needs

b

Comparing outcomes with original goals

c

Determining the client’s financial constraints

d

Clarifying roles of interprofessional team members

a Coordinating services to meet the client’s needs

Technology and Community Nursing

Advances in technology have changed health care delivery, disrupting old methods and creating new opportunities.

Technology can help with cost control → compare expense vs. potential savings before implementation.

Nurses can use technology to:

• Increase awareness and provide education (social media campaigns, surveys, health literature databases)

• Collect data for community/public health

Technology increases life expectancy but may also create ethical dilemmas.

Nurses must stay updated on new technologies → affects quality of care and community health outcomes.

Informatics

Combines nursing science + information/communication technology.

Examples:

• EHR (Electronic Health Records), EMR (Electronic Medical Records), databases, billing systems

• Smartphones, hand-held computers, GIS (Geographic Information Systems), internet tools

Uses:

• Support interprofessional meetings (chatrooms, asynchronous discussions)

• Alternative delivery methods for client education

• Facilitate support groups, peer collaboration, staff training

Telehealth

Delivery of quality health care via technology.

Particularly useful in rural areas → increases access to specialized/skilled nursing care.

Uses include:

• Home care services (clients at home, nurses in centralized location)

• Must balance telehealth with hands-on care for best outcomes

Agencies use telehealth for electronic health data transmission (ensures confidentiality/security).

Telecommunications support physical, audio, visual data transfer.

Data Types in Telehealth

Physical Data

• Blood pressure

• Weight

• Blood oxygenation

• Blood glucose

• Heart rate

• Temperature

• ECG results

Audio Data

• Voice conversations

• Heart sounds

• Lung sounds

• Bowel sounds

Visual Data

• Images of wounds

• Images of surgical incisions

Other Uses for Technology

Outreach/education: ex. public service announcements (e.g., intimate partner violence prevention, resource connection)

Electronic record keeping in public health:

• Client records

• Document services provided

• Maintain financial records

• Manage organizational plans

Partnerships with Legislative Bodies

Laws/decisions profoundly affect health outcomes.

Health policy regulates licensing, scope of practice, negligent care, and responsibilities in different settings (e.g., schools, corrections).

Nursing Responsibilities

• Stay informed about current policy and laws impacting community & nursing practice.

• Advocate for policies that:

  • Protect public health

  • Offer solutions to community problems

• Communicate with policymakers to present evidence-based solutions to major health problems.

• Ensure equitable distribution of resources (SDOH).

Nurses’ Role in Health Policy

Change Agents → Advocate for needed change at the local, state, or federal level.

Lobbyists → Persuade or influence legislators; can be done by individuals or nursing associations.

Coalitions → Facilitate achievement of goals through collaboration between two or more groups.

Public Office → Nurses can serve in public office to advocate for change and influence policy development.

A nurse is reviewing the various roles of a community health nurse. Match each action to the example of the community health nurse function. ​​​​​​​

Advocate

Consultant

Coalition builder

Lobbyist

Case manager

Counselor

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Updating local officials about the need for activities to prevent youth violence

Contributing to policy development for state funding of prenatal programs

Working with a childcare center on handwashing to reduce the spread of communicable diseases

Collaborating with an interprofessional team to provide continuity of care after hospitalization

Bringing together community agencies to implement a community garden

Establishing an interpersonal relationship with a family to enhance their self-care and coping abilities

Updating local officials about the need for activities to prevent youth violence

• Advocate

Contributing to policy development for state funding of prenatal programs

• Lobbyist

Working with a childcare center on handwashing to reduce the spread of communicable diseases

• Consultant

Collaborating with an interprofessional team to provide continuity of care after hospitalization

• Case manager

Bringing together community agencies to implement a community garden

• Coalition builder

Establishing an interpersonal relationship with a family to enhance their self-care and coping abilities

• Counselor