L

Chapter 12: Interprofessional Collaborative Practice and Care Coordination Across Settings

Chapter 12: Interprofessional Collaborative Practice and Care Coordination Across Settings

Community Health

  • Context: Chapter focuses on interprofessional collaborative practice and care coordination across different settings within community health.

  • Document context: Wolters Kluwer material referencing the chapter title and date (9/11/2025).

Healthy People 2030 and Leading Health Indicators

  • Healthy People 2030 (HP 2030) provides leading health indicators to guide public health priorities.

  • Implication: Indicators help identify where collaborative practice and care coordination should focus to improve population health outcomes.

  • Note: The transcript references "Healthy People 2030—leading health indicators" as a guiding framework for assessing community health needs and priorities.

Johns Hopkins Hospital Community Health Needs Assessment (CHNA)

  • CHNA purpose: Systematic assessment of health needs in the community to inform planning and resource allocation.

  • CHNA components mentioned:

    • Socioeconomic needs

    • Direct health needs

  • Definition to remember: CHNA is a structured process used by health systems to understand community health requirements and guide interprofessional collaboration across settings.

CHNA: Socioeconomic Needs

  • Listed socioeconomic determinants identified in the CHNA:

    • Employment

    • Crime / neighborhood safety

    • Housing / homelessness

    • Education

    • Food environment

  • Significance: Socioeconomic factors influence health outcomes and access to care; addressing these needs requires cross-sector collaboration (housing, policing, education, nutrition programs, employment services).

CHNA: Direct Health Needs

  • Direct health needs identified in the CHNA include:

    • Behavioral health / substance use

    • Mental health

    • Chronic diseases

    • Uninsured or underinsured status

    • Dental services

  • Note: These are immediate health care needs that hospitals and community health organizations must address through coordinated care.

CHNA Focus Areas

  • CHNA focuses on several integrated domains:

    • Transportation

    • Overall health

    • Mental health

    • Dental health

    • Safety

  • Significance: These areas influence access to care, utilization of services, and overall population health; targeting these areas supports effective care coordination across settings and levels of care.

Community-Based Health Care

  • Definition: Health care provided to people who live within a defined geographic area.

  • Purpose in the context of interprofessional practice: Ensure health services are accessible within the community and are tailored to local needs.

  • Role in care coordination: Bridges gaps between different care settings by focusing on population health within a locale and facilitating follow-up and continuity of care.

Nurses in the Community: Roles and Responsibilities

  • Key roles of nurses working in the community:

    • Provide continuity of care when a patient moves from one level of care to another or from one setting to another

    • Provide interventions to promote health

    • Manage acute or chronic illness

    • Promote self-care

  • Significance: Nurses serve as the continuity link across settings (home, primary care, specialty care, hospitals) and are essential for timely interventions, disease management, and empowering patients for self-management.

Connections to Interprofessional Practice and Care Coordination Across Settings

  • Interprofessional collaboration is essential to integrate socioeconomic and direct health needs into a cohesive care plan.

  • Care coordination across settings relies on accurate information sharing, consistent follow-up, and alignment of goals across clinicians, social services, and community resources.

  • Real-world relevance: Improved transitions of care, reduced readmissions, enhanced access to essential services (e.g., dental, mental health, transportation), and better health outcomes in the community.

Ethical, Practical, and Foundational Implications

  • Ethical considerations: Addressing social determinants (socioeconomic needs) to reduce health inequities; ensuring access for uninsured/underinsured populations.

  • Practical implications: Requires cross-professional teams, shared care plans, and alignment with community resources and CHNA findings.

  • Foundational principles: Population health, primary care coordination, and patient-centered care across settings.

Summary Takeaways

  • CHNAs (e.g., CHNA by Johns Hopkins Hospital) identify key socioeconomic and direct health needs to guide interprofessional collaboration.

  • HP 2030 provides leading health indicators to frame priorities for action.

  • Community-based health care targets a defined geographic area to improve access and continuity of care.

  • Nurses in the community play a critical role in continuity of care, health promotion, chronic disease management, and self-care support.

  • Effective care coordination across settings depends on addressing both socioeconomic determinants and direct health needs through interprofessional teamwork and community partnerships.