NURS 320: Care Coordination Hybrid Lecture

Understanding the fundamental aspects of care coordination
Knowing how to apply care coordination principles when preparing for the upcoming exam
Identifying various roles within a healthcare team related to care coordination

Care Coordination: A set of activities organized by a team of personnel that includes the patient, facilitating the delivery of necessary services and information to support optimal health and care across various healthcare settings.
- Goals: To connect services, resources, and personnel to achieve optimal healthcare outcomes.
- Components:
  - Interorganizational and interprofessional teamwork
  - Patient and family involvement
  - Effective communication and information exchange

Nurse's Responsibilities:
- Facilitate communication between different healthcare system facets (e.g., hospitals, skilled nursing facilities, home care).
- Coordinate care teams involved in managing patient care.
- Develop proactive plans of care, inclusive of SMART goals.
  - SMART Goals: Specific, Measurable, Attainable, Relevant, Time-Based objectives designed for patient care.
- Implement evidence-based activities targeted towards achieving health goals.
- Ensure proactive follow-up with patients to assess their care transitions.

Navigating the complex healthcare system can lead to:
- Delayed or limited access to care due to a lack of coordination.
- Overwhelming experiences for patients with limited healthcare knowledge.
Centering Care:
- Empowers the patient and family, ensuring their needs are prioritized in care plans.
- Involves collaborations from various healthcare team members (e.g., pharmacists, doctors, nurses, behavioral health providers).

Health Conditions:
- High cholesterol: Related concept -> Impaired perfusion
- Obstructive sleep apnea: Related concept -> Altered sleep and rest
- Bilateral knee pain: Related concept -> Altered mobility
- Type 2 diabetes: Related concept -> Altered hormone regulation
- Depression: Related concept -> Altered mood and affect
Care Coordination Needs for Each Condition:
- High Cholesterol:
  - Need for medication from doctor or nurse practitioner
  - Need for pharmacy education on medication usage
  - Family involvement in managing child’s health
- Sleep Apnea:
  - Device (e.g., CPAP) prescribed and ordered by providers
  - Home health supply distributors for support
  - Family education on equipment use
- Knee Pain:
  - Consultation from doctors, nurses, potential physical therapy
  - Nutrition counselling to aid in weight loss
- Type 2 Diabetes:
  - Medication management by healthcare professionals
  - Connection with pharmacy for glucose monitoring tools
  - Family and provider education on managing diabetes
- Depression:
  - Possible referral to behavioral health services for therapy or counseling

Situation: Child is discharged after hospitalization for hypoglycemia and dehydration.
SMART Goal: "The client and parents will verbalize the correct dose and administration of Metformin immediately after instruction today."
- Specific: Focused on medication administration knowledge.
- Measurable: Verbal confirmation demonstrates understanding.
- Attainable: Actionable following educational instruction.
- Relevant: Directly related to hormone regulation and diabetes management.
- Time-Based: Must achieve understanding by the end of the instruction session.

High Need Populations:
- Older adults
- Young children
- Individuals with disabilities (hard of hearing, blind, etc.)
- Those with complex or chronic health conditions (e.g., diabetes leading to complications)
- Pregnant women with high-risk factors
- End-of-life patients
At-Risk Populations for Poor Coordination:
- Houseless individuals
- Underinsured or uninsured patients
- Individuals with mental health or behavioral health issues

Challenges in Accessing Care:
- Lack of transportation, finances, or home addresses can significantly hinder access to healthcare services.
Medicare and Medicaid Overview:
- Medicare: Federal program for individuals 65 or older and some younger with disabilities.
- Medicaid: Joint federal/state program aiding medical costs for eligible individuals with limited income/resources.
Importance of Understanding Insurance Limitations:
- Even insured patients may face barriers based on non-coverage of specific services.

County Social Services:
- Assist patients in obtaining essential services such as utilities, housing, transportation, and food to reduce redundancies in care.
Example Resources in Yamhill County Area:
- Providence Newberg Diabetes Clinic: Offers diabetes care to the community.
- Qile Medical Nutrition Care: Provides diabetes support groups and nutrition assistance.
- Aging and Disability Resource Connection: Facilitates workshops for at-home diabetes management.

Prepare for class participation using digital devices for interactive learning and assessment on care coordination topics.
Ensure engagement with the practical application of care coordination concepts based on case studies discussed.