NUR460 Midterm test

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Questions and Answers

What is a critical first step in the transition planning for youth with chronic medical conditions?

Discontinue pediatric care at age 16

Schedule appointments with specialists immediately

Assess transition readiness of patients and caregivers (correct)

Increase medication dosages before transition

Why is it essential to create an individualized transition plan?

To expedite the transitioning process as much as possible

To minimize communication between the family and healthcare providers

To ensure all patients are treated with the same approach

To address specific care needs of youth and their families (correct)

What is one of the core principles in transition planning?

Planning should be standardized for all patients

Delayed planning until the youth is 18 years old

Support and education should occur prior to transition (correct)

Avoiding connection with service providers

How can families help coordinate care in a new healthcare system?

By maintaining communication and involvement in the process Signup and view all the answers

When is the ideal age to start transition planning for youth with chronic medical conditions?

Around ages 12-14 Signup and view all the answers

What is a potential challenge for adult care practitioners when treating children with complex care needs?

Insufficient education about pediatric conditions Signup and view all the answers

What is an effective strategy to enhance youth independence during the transition process?

Implement a gradual increase in care management responsibilities Signup and view all the answers

How should ongoing support be provided post-transition?

Through continuous assessment and adapting care plans as necessary Signup and view all the answers

What is a key strategy to reduce the shock experienced by patients and families during the transition to adult care?

Initiate referrals prior to the 18th birthday Signup and view all the answers

Which of the following is not a recommended aspect of individualized transition planning?

Providing minimal information about future medical needs Signup and view all the answers

What role does government funding play in the transition to adult care for youth with complex health needs?

It supports funding transition and future planning Signup and view all the answers

What is one of the main challenges faced during the transition from pediatric to adult care?

Fragmentation of pediatric and adult care services Signup and view all the answers

How can capacity be built in adult care for youth with childhood onset conditions?

Through early introduction to the adult system Signup and view all the answers

What is essential for ensuring continuity of care during the transition to adult services?

Establishing connections to care prior to transition Signup and view all the answers

What should be continuously assessed after the transition to adult care?

Youth's attachment to adult services Signup and view all the answers

Which of the following conditions is associated with worsened outcomes post-transition?

Cystic fibrosis Signup and view all the answers

What is one of the primary benefits of integrated care systems?

Improve continuity of care Signup and view all the answers

Which aspect is NOT emphasized in effective care coordination?

Care provided in isolation Signup and view all the answers

How does nurse-led care coordination benefit patients?

Improves communication between healthcare staff Signup and view all the answers

Which of the following is a key activity in the nursing care coordination model for medically complex patients?

Activities that link patients with services and a multidisciplinary team Signup and view all the answers

What is a common risk associated with transitions of care?

Increased patient morbidity and mortality Signup and view all the answers

What is meant by care coordination?

Ensuring smooth transitions and communication between care levels Signup and view all the answers

Which factor is NOT typically considered in the choice of care coordination?

Severity of the weather Signup and view all the answers

What approach can enhance the safety of vulnerable patients during care transitions?

Nurse-led care coordination Signup and view all the answers

Which of the following best describes the holistic approach in patient care?

Considering emotional and spiritual health along with physical health Signup and view all the answers

What is a critical outcome that effective transitions of care aim to prevent?

Preventable readmissions to hospitals Signup and view all the answers

Study Notes

Integrated Health Care System

Shift from fragmented to integrated healthcare
Emphasizes coordinated care across all levels and within communities
Potential to improve:
- Continuity of care
- Accessibility
- Quality and safety
- Cost-effectiveness
Encourages holistic patient view and closed-loop communication

Models of Integrated Care

Care coordination is crucial for success
No single, globally accepted model, but care coordination is agreed upon
Various approaches:
- Case management
- Patient navigation
- Collaborative care
- Disease management
- Care management
- Chronic care model

Effective Care Coordination

Multidisciplinary primary care team functioning cohesively
Care coordinator role can be filled by professionals from various backgrounds (nursing, social work, OT, PT, etc.)
Team-based approaches are also possible
Choosing a care coordinator involves considering contextual factors, target population, and program goals
Role can be exclusive or combined with wider team management or clinical care provision

Nurse-Led Care Coordination

Improvements:
- Access to appropriate treatment
- Cost reduction
- Clinical outcomes
- Quality of care
- Staff communication
- Safety for vulnerable patients during transitions
- Reduced unplanned readmissions
- Reduced medication errors, or errors due to lack of education

A Model of Nursing Care Coordination for Medically Complex Patients

Three categories of activities
- Targeting patient and family
- Linking patients to services and multidisciplinary teams (MDT)
- Targeting the MDT
Interrelation of these categories is key
Aligning care to what works for patients at home to prepare them for similar care at home
- Adapting to their schedules

What is Your Role in Caring for Medically Complex Patients?

Support treatment and connection
Provide continuity, expertise in practice area, and system navigation
Offer opportunity to support goal-setting, joint decision-making, partnership, and discussions about goals of care and advance care planning
Families seek medical expertise, support, guidance, and partnership

Transitions of Care

Actions designed to ensure coordinated and continuous healthcare during patient transfers between locations or care levels
- Home to hospital or residential care
- Hospital to home
- Between hospital wards
- From hospital to hospital or residential care setting
- Outpatient facility consultations
Transitions of care are high-risk scenarios for patient safety
- Increased morbidity
- Increased mortality
- Increased adverse events
- Delays in receiving appropriate treatment and community support
- Additional primary care emergency department visits
- Additional or duplicated tests or test losses to follow-up
- Preventable readmissions to hospital
- Emotional and physical pain and suffering for patients, caregivers and families
- Patient and provider dissatisfaction with care coordination
Transfer: ensures safe and efficient transfer of responsibility with all necessary information for client care provided to the receiver

Intersection of Risk Factors

Factors associated with patient transitions:
- Patient factors
  - Vulnerable populations: elderly, pediatrics
- Personnel factors
  - Receiving personnel: who and when
- System factors
  - Mode of transfer

Need for Transition Support

Families have to coordinate care in a new and fragmented system
Increased demand for treating children with complex care, which adult care practitioners may not be trained for
Increased anxiety for care providers and patients

Core Principles of Transition Planning

Start early
Individualized planning
Provide support before transition
Ensure ongoing support

Start Transition Planning Early

Regularly assess transition readiness of patients and caregivers
Ensure adequate dedicated time for the transition process
Understand youth's potential and goals for activity, education, recreation, and vocation
Ideal age: 12-14 years old
- Start transition slowly
Good time to connect with a family care provider around 14 years old
- Maintain pediatric care while establishing a family HCP
17 years old: good age for specialist connections

Create an Individualized Transition Plan

Identify a transition "champion"
Identify key multidisciplinary clinicians and primary care
Solicit care needs from youth and parents/caregivers
Address gaps in youth preparedness, autonomy, and confidence
Develop a transition plan
- Comprehensive medical summary and anticipatory guidance
- Transition readiness checklist completion
- Regular review and update of transition plan
- Developmentally appropriate care and support

Provide Support Before Transition

Education and peer support for youth and caregivers
Support youth with a stepwise approach to increasing independence in care management
Create a comprehensive health transfer summary based on youth and caregiver priorities
- Include strengths, hopes, and quality-of-life considerations
Provide summary to youth and clinicians
- "My Health" 3-sentence summary
  - Age, diagnosis, and brief medical history
  - Treatment plan
  - Questions or concerns for the visit

Provide Support Before Transition: Connection to Primary Care Provider

Use healthcare connect to find a doctor or NP
Joining healthcare connect does not guarantee
- Finding a family HCP
- That one family HCP can take the whole family

Provide Support Before Transition: Funding Transition and Future Planning

Government funding
- Developmental Services Ontario (DSO)
- Ontario Disability Support Program (ODSP)
Private funding options
- Registered Disability Savings Plan
- Henson Trust

Provide Support Before Transition: Overlap in Care

Initiate referrals before the 18th birthday
Build capacity in adult care providers for childhood-onset conditions
Early introduction to the adult system
- Adult care focuses on independence and personal care management
Ensure connection to care for continuity and collaborative practice

Ensure Ongoing Support After Transition

Ensure youth attend appointments
Assess youth's attachment to adult services
Continue to involve caregivers according to the youth's wishes, with gradual weaning over time
Measure outcomes routinely

The Take Home on Transition to Adult Care

Start early
Overlap in care
Individualized transition planning
Capacity building and self-directed care
Build connections in the adult system
Ensure primary care provider connection
Medical summary and anticipatory future needs
- Consider what the youth will need when they grow up or down the line (i.e., having children)

Summary/Key Points: Recommendations to Improve Transition to Adult Care for Youth with Complex Health Needs

Youth with complex health needs: require specialized physical, developmental, and/or mental health services, transitioning from pediatric to adult care typically between ages 16-19 in Canada.
Challenges in transition:
- Fragmentation in pediatric and adult care services disrupts continuity, risking poor health outcomes.
- Youth face multiple challenges, including physical, psychosocial, and developmental changes.
- Conditions such as diabetes, cystic fibrosis, congenital heart disease, and organ transplants see worsened outcomes post-transition.
- Gaps in care during transition lead to patient disengagement, poor treatment adherence, and increased hospitalization.

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