Community Care Services Overview

Study Notes

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.

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.

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-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.

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.

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.