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Patient-Care Delivery System/ Modalities of Nursing Care
It refers to the manner in which nursing care is organized and delivered.
Philosophy of the Organization
Nurse Staffing
Client Population
Modalities of Nursing Care refers to the manner in which nursing care is organized and delivered. Depending on the PNC
Case Method/Total Patient Care
Nurses assume total responsibility for meeting all the needs of assigned patients during their time of duty.
OLDEST
Case Method/Total Patient Care is the ______ mode of organizing patient care
case method of assignment
Case Method/Total Patient Care sometimes referred to as the ________, because patients may be assigned as cases
autonomy and responsibility
In Case Method/Total Patient Care, the nurse cares for one or a few patients whom the nurse cares for exclusively. Provides nurses with high _____ and ______.
Quality of care—all care is delivered by a registered nurse
Continuity of care for a given shift
High patient satisfaction
Decreases communication time between staff
Reduces the need for supervision
Allows one person to perform more than one task
Advantages of Case Method/Total Patient Care: QCH DRA
It can be very costly.
Confusing to the patient, the nurse modifies the care regimen during every shift.
Tasks can be done by someone with less training, less experience, and low cost.
Disadvantages of Case Method/Total Patient Care: CCL
Primary Nursing
The primary nurse assumes 24-hour responsibility for planning the care of one or more patients from admission or the start of treatment to discharge or the treatment’s end.
During work hours, the primary nurse provides total direct care for that patient. When not in duty, associate nurses follow the care plan established by the primary nurse.
Originally, primary nursing was designed for use in hospitals, but it can lend itself well to home health nursing, hospice nursing, and other health-care delivery enterprises as well.
Integral responsibility is to establish clear communication among the patient, physician, associate nurses, and other team members.
Uses some of the concepts of total patient care and brings the RN back to the bedside to provide clinical care Holistic, high-quality patient care given through the combination of clear interdisciplinary group communication and consistent, direct patient care by relatively few nursing staff.
relationship-based nursing
Primary nursing is also known as
Population health management
Comprehensive assessment and care planning
Interpersonal communication
Education/coaching
Health insurance and benefits
Community resources
Research and evaluation
The seven domains required for primary care coordination included the following: PCIE HCR
Population health management
A change from a focus on a single provider caring for the health and well-being of an individual patient to a focus on a health-care team managing the health of a panel of patients.
Comprehensive assessment and care planning
A thorough knowledge of chronic disease management and evidence-based guidelines and protocols, especially for chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), diabetes, and depression.
Interpersonal communication
Includes the ability to use different communication styles, including active listening, to counsel, interview, resolve conflict, build relationships, and develop effective interdisciplinary teams.
Education/coaching
A working knowledge of adult education principles and learning techniques, readiness to change, and identification of necessary person centered components for a self-management plan.
Health insurance and benefits
Current knowledge of health insurance, managed care, and other payer sources and benefits.
Community resources
A thorough familiarity of public and private community based providers, services, and support available in the local geographical area.
Research and evaluation
A basic understanding of research and evaluation techniques to assist in quality improvement of care and interpretation of program outcomes.
Job satisfaction is high
More professional system: RN plans and communicates with all healthcare members.
RN develops skills and feel challenged and rewarded at the same time.
Advantages of Primary Nursing: JMD
Difficult degree of responsibility and autonomy of the primary nurse.
Difficult to retain and recruit RN to be PN, especially in times of nursing shortage.
Disadvantages of Primary Nursing: DR
Team Nursing
One of the recommendations of the 2010 Institute of Medicine Report, was to expand the opportunities for nurses to lead and diffuse collaborative improvement efforts with physicians and other members of the health-care team to improve practice environments
Incorporate pharmacists, social workers, occupational therapists, speech therapists, and other health-care workers as part of the multidisciplinary team to assure that comprehensive and holistic health care can be provided to each patient, although the responsibility for team leadership still often falls to the RN. Require an efficient means of communication about patient goals, progress, and problem.
Implementation problems are common, however, in multidisciplinary teams, having experts on teams is different than having expert teams; each discipline may believe that their perspective is most important and undervalue the contributions of other team members.
Developed that reduced the fragmented care that accompanied functional nursing. Ancillary personnel collaborate in providing care to a group of patients under the direction of a professional nurse.
As the team leader, the nurse is responsible for knowing the condition and needs of all the patients assigned to the team and for planning individual care.
Team conferences occur in which the expertise of every staff member is used to plan the care.
The Team Leader has a core of staff reporting to her, and together they work to disseminate the care activities.
The team leader’s duties vary depending on the patient’s needs and the workload.
Assisting team members
Giving direct personal care to patients
Teaching,
Coordinating patient activities
Duties of team leaders: AGTC
Job satisfaction is moderate to high, depending on the member’s capabilities
Patients have one nurse (the Team Leader) with immediate access to other health providers.
Advantages of Team Nursing:
Requires a team spirit and commitment to succeed.
RN may be the Team Leader one day and a team member the next, thus continuity of patient care may suffer.
Care is still fragmented, with only 8 or 12 hour of accountability
Disadvantages of Team Nursing:
Modular Nursing
Uses a mini-team (two or three members with at least one member being an RN)
It is a geographical assignment of patient that encourages continuity of care by organizing a group of staff to work with a group of patients in the same locale.
care pairs
The members of the modular nursing team sometimes is called ____
modules or districts
In Modular Nursing, patient care units are typically divided into ____
Useful when there are a few RNs
RNs have more time to plan their care
Advantages of Modular Nursing:
Paraprofessionals do the technical aspects of nursing care
Disadvantages of Modular Nursing:
Functional Nursing
Is a task-oriented method wherein a particular nursing function is assigned to a specific member. Work assignments by functions or tasks such as giving medications, changing of dressings, giving TSB’s, or taking vital signs.
Advantage is there is no role confusion. You knew what you were doing. This method is efficient and cheap.
Disadvantage is the client could not identify who their caretaker was because there were so many caretakers.
function
In functional nursing, assignment is by ____
A very efficient way to delivery care.
Could accomplish a lot of tasks in a small amount of time
Staff members do only what they are capable of doing
Least costly as fewer RNs are required
No role confusion.
Advantages of Functional Nursing:
Care of patients become fragmented and depersonalized
Patients do not have one identifiable nurse
Very narrow scope of practice for RNs
Leads to patient and nurse dissatisfaction
Disadvantages of Functional Nursing:
Nursing Case Management
“A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes”. (CMSA)
Often begin in the hospital inpatient setting, with length of stay (LOS) and profit margin per confinement used as measures of efficiency, but now they frequently extends to outpatient settings as well
case management
helps patients access community resources, helps patients learn about their medication regimen and treatment plan, and ensures that they have recommended tests and procedures.
Acute care case management
integrates utilization management and discharge planning functions and may be unit based, assigned by patient, disease based, or primary nurse case managed.
All professionals equal team members
Members take ownership of patient outcomes
Advantages of Nursing Case Management:
Requires qualified nurse case manager, team collaboration, and quality management system
Established critical pathways needed
Disadvantages of Nursing Case Management:
Critical pathways/Clinical pathways
A strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care.
Reflect relatively standardized predictions of patients’ progress for a specific diagnosis or procedure.
provides some means of standardizing care for patients with similar diagnoses
Advantages of Critical/Clinical Pathway:
difficulties they pose in accounting for and accepting what are often justifiable differentiations between unique patients who have deviated from their pathway.
Disadvantages of Critical/Clinical Pathways
variance analysis
Patient progress that differs from the critical pathway prompts a _____
Multidisciplinary action plans (MAPs)
a combination of a critical pathway and a nursing care plan. It indicates times when nursing interventions should occur. It facilitate expected outcomes.
Disease Management
Also known as population-based health care and continuous health improvement, is a comprehensive, integrated approach to the care and reimbursement of high-cost, chronic illnesses.
address such illnesses or conditions with maximum efficiency across treatment settings regardless of typical reimbursement patterns.
One role that is increasingly assumed by case managers is coordinating disease management (DM) programs. The goal of DM is to
covered lives
In DM, Focus is on “_______” or populations of patients, rather than on the individual patient. Goal is to service the optimal number of covered lives required to reach operational and economic efficiency.
Provide a comprehensive, integrated approach to the care and reimbursement of common, high-cost, chronic illnesses.
Focus on prevention as well as early disease detection and intervention to avoid costly acute episodes but provide comprehensive care and reimbursement.
Target population groups (population based) rather than individuals.
Employ a multidisciplinary health-care team, including specialists.
Use standardized clinical guidelines—clinical pathways reflecting best practice research to guide providers.
Use integrated data management systems to track patient progress across care settings and allow continuous and ongoing improvement of treatment algorithms.
Frequently employ professional nurses in the role of case manager or program coordinator.
Common Features of Disease Management Programs
Innovative/Contemporary Method
Health care delivery models are continuing to emerge that expand the role of nurses beyond direct caregivers.
A white paper entitled Innovative Care Delivery Models: Identifying New Models That Effectively Leverage Nurses, was published by Health Workforce Solutions in 2008.
This white paper suggested that nurses form the backbone of almost all these new models and that eight common themes could be identified among the most successful care delivery.
Nurse Navigators
Serves as a clinician, care coordinator, educator and counselor for patients and families.
Help patients and their families understand the diagnosis and treatment plan.
Improves patient outcomes through education, support and monitoring.
Coordinates care with other health care providers such as radiologist, pharmacist, dietitians social workers, case managers and counselors.
Help the patient and family connect with community resources (working with social workers with expertise in this area)
Remain available and in contact with the patient and caregivers throughout the treatment process; the patient may call at any time day or night with question about medication, symptoms, lifestyle changes, or other concerns.
Is a relatively new role for professional nurses.
t helps patients and families navigate the complex health care system by providing information and support.
Acts as a guide, resource, advocate, educator, and liaison for newly diagnosed cancer patients and their family.
consistent caregiver through the cancer journey, coordinating appointments and schedules while keeping the patient and family actively involved in their plan of care.
oncology
Nurse Navigation commonly occurs in targeted clinical settings such as ____, whereby a breast cancer nurse navigator might work with a woman from the time she is first diagnosed and then follow her throughout the course on her illness.
master’s degree in nursing
The CNL, as an advanced generalist with a _____ degree in nursing, is expected to provide clinical leadership at the point of care in all health-care settings, implement outcomes-based practice and quality improvement strategies, engage in clinical practice, and create and manage microsystems of care that are responsive to the health-care needs of individuals and families (AACN, 2007).
Clinical Nurse Leaders
____ have advanced knowledge and education in general practice as opposed to one primary discipline, like Clinical Nurse Specialist (Johnson & Johnson Services Inc., 2015).
provider and a manager
The CNL then is a _______ at the point of care to individuals and cohorts and as such designs, implements, and evaluates client care by coordinating, delegating, and supervising the care provided by the health-care team (AACN, 2007).
interdisciplinary
The CNL also plays a key role in collaborating with _______ teams.
risk analysis strategies and resources
CNL as a leader of these teams identifies ________ needed to ensure the safe delivery of care and then relies on patient-centered, evidence-based practice and performance data to make needed decisions (RWJ, 2009).
point person
At the Veterans Affairs, CNLs serve as the ____ on patient care teams and are leaders in the health-care delivery system.
Planetree, 2014
The philosophy of patient-centered care is based on the premise that care should be organized first and foremost around the needs of patients
right thing to do
Planetree argues that patient-centered care is the “____” Thus, it humanizes, personalizes, and demystifies the patient experience.
Planetree
IPFCC
According to Warren (2012), the two most prominent pioneers in developing and promoting patient- and family-centered care:
Planetree
a mission based not-for-profit organization that provides partners with healthcare organizations around the world and across the care continuum to transform how care is delivered.
Informs policy at a national level
Aligns strategies at a system level
Guides implementation of care delivery practices at an organizational level
Facilitates compassionate human interactions at a deeply personal level
Guided by a foundation in 10 components of patient centered care, Planetree;
Informs policy at a _____ level
Aligns strategies at a ______ level
Guides implementation of care delivery practices at an _______ level
Facilitates compassionate human interactions at a deeply _____ level
The IPFCC
a not-for-profit organization offering health-care providers and institutions information and core guiding concepts related to patient- and family-centered care.
Open visitation
Family presence during all procedures
Patient, family, and staff communication and collaboration in care plan development, multidisciplinary rounds, and bedside handoffs between nurses
Information availability in patient and family resource centers
And the use of patient and family advisors in performance and safety improvement efforts.
In addition, the model encourages the use of soft colors, lighting, home-like fabrics, and music for patient rooms and common areas as well as opportunities for patients and families to learn about their illness in order to foster participation in their care.
Under The IPFCC
These concepts include:
According to Abraham and Moretz (2012)
Nurses must act as catalysts for initiating and integrating the health-care provider, patient, and family partnership practices in daily care.
Agrees that “no matter what one’s nursing role—clinical, educational, administrative—it is possible to champion patient- and family-centered change so true collaboration with patients and families becomes embedded in the organizational culture”
This requires the leadership skills of vision, planned change, team building, and collaboration.
Vision
Planned change
Team building
Collaboration
According to Abraham and Moretz (2012), this requires the leadership skills of VPTC