Community Care Services Overview

Overview of Community Care Services

• Community Care is a coordinated system providing home and community-based services for individuals with disabilities and chronic or acute illnesses.
• Services primarily delivered by registered nurses and certified personal care workers.
• Delivery is based on assessed needs, using a case management approach.

Goals of Community Care Services

• Plan and deliver comprehensive, culturally sensitive home care services.
• Help individuals with chronic/acute illnesses maintain health and independence.
• Ensure community access to home care services for clients in need.
• Engage clients and families in creating and implementing care plans, while utilizing community support.

Elements of Community Care Services

• Client/Community Assessment:

  • Ongoing assessments to identify client needs and appropriate services.
  • Involvement of clients, families, and caregivers is vital for effective chronic condition management.
  • Target populations with higher risk factors to address health inequalities and improve overall population health.

• Information and Data Collection:

  • Systematic record keeping for client health records to monitor programs and evaluate success.

• Management, Supervision, and Monitoring:

  • Focus on safe, quality care delivery, identifying health trends, and measuring program effectiveness.
  • Goals include reducing health inequalities and promoting early intervention.

• Established Linkages with Other Services:

  • Collaborate with healthcare providers, hospitals, and community services for coordinated care.
  • Multidisciplinary teams help integrate services and minimize care fragmentation.
  • Team approach reduces missed appointments, hospitalizations, and healthcare costs.

• Additional Support Services:

  • Services may include rehabilitation, adult day care, meal programs, mental health support, and wellness initiatives.

Community Nursing Care Focus

• Community-based nursing enhances health, minimzes disease progression, and boosts quality of life.
• Care is individualized with emphasis on cultural and community contexts, prioritizing self-care and preventive measures.

Key Concepts in Community Nursing

• Assessment:

  • Evaluate health, community, and home environments, including support systems and safety measures.
  • Important factors include family capabilities and accessible resources for recovery.

• Establishing Goals:

  • Collaboration with patients and families to set healthcare goals.
  • Goals should originate from mutual communication to reflect patient values and preferences.

• Plan Development:

  • Formulate a realistic plan with clear criteria for monitoring progress.
  • Involves prioritizing care strategies and coordinating with other healthcare professionals.

• Identifying Barriers:

  • Recognize environmental, social, and psychological factors impeding goal attainment, such as financial constraints.

• Implementation of Interventions:

  • Actions may include providing care, advocacy, education, counseling, and resource management.
  • Continual reassessment and documentation of the patient’s response to care is necessary.

Health Education for Chronic Illness Management

• Education fosters active participation and responsibility in personal care to prevent crises and re-hospitalization.
• Encourages adherence to therapeutic regimens requiring lifestyle changes to support health maintenance.
• Effective education helps individuals adapt to illness and manage complications effectively.