Client-Centered Care Coordination

Client Centered Care Definition

Set of activities purposefully organized by a team of personnel that includes patient to facilitate the appropriate delivery of necessary services and information to support optimal health and care across settings and overtime

Antecedents of Client Centered Care

Client requiring multiple services, interaction of multiple healthcare team members, communication

Defining Characteristics of Client Centered Care

Interprofessional team that includes patient, communication exchange, proactive plan of care with goals, follow-up

Positive Consequences of Client Centered Care

Goals develop with client input, multiple needs of client met, positive communication, trust, improved client outcomes

Risk Factors of Client Centered Care

Lack of process and lack of resources

Negative Consequences of Client Centered Care

Reactive/fragmented care, mismanagement of resources, lack of trust, lack of communication, unmet patient/family needs

Vulnerable Populations of Client Centered Care

Perioperative, mental health, frail elderly, preterm infants, pregnancy, special needs, palliative care

Patient Factor Interrelated Concepts of Client Centered Care

Adherence, development, culture, functional ability, self-management, family dynamics

Nursing is the…

Protection, promotion, and optimization of health and abilities, prevention of illness + injury, facilitation of healing, alleviation of suffering, advocacy for patient

What are care management programs designed to prepare nurses for?

Provide comfort and dignity in life and death and to promote/maintain health

What is the purpose of the care management process?

To enhance health states, functional abilities, and quality of life for individuals/families/populations

What is the care management process model oriented on?

Outcomes-oriented of individual and group

Nurses collaborate with patients, families, communities. Other professionals serve as:

Managers of care, change agents, and advocates for outcome improvement

Components of Care Management Process

1. Population Identification

2. Expected/Desired Outcomes Identified + Prioritized

3. Assessment

4. Variance Identification

5. Interventions/Strategies

6. Evaluation of Care + Outcomes

7. Modification

Population Profile

Brief and concise paragraph that describes the relationship of a health alteration

What does the population profile serve as the foundation of?

For the development of interventions at the health promotion and health protection levels of cary delivery by the care manager

SMART Goals

Specific
Measurable
Achievable
Relevant
Time-Specific

After identifying the expected outcomes, you must assess…

Your client, family, group, or community in order to determine the status of your client in relation to the expected outcomes

What helps determine which assessments are needed and what information or data are more important?

Knowledge of the population and the issue/need/disease

What does disease management involve?

Understanding and treating the disease across populations and across the continuum of care

What does care management focus on?

Individual client, family, group, or community in the context of the disease