Care Coordination 2024 - Student Copy.pdf

Care Coordination Exemplars: Discharge Planning, Children with special needs, Frail elderly, Chronic illness, Care continuum (mental health, end-of-life care) Rebecca Jones MN, RN, GNC(C), LC NRSG3101 – Fall 2024 What is Care Coordination? *A professional standard and essential competency of t...

Care Coordination Exemplars: Discharge Planning, Children with special needs, Frail elderly, Chronic illness, Care continuum (mental health, end-of-life care) Rebecca Jones MN, RN, GNC(C), LC NRSG3101 – Fall 2024 What is Care Coordination? *A professional standard and essential competency of the Registered Nurse* Essential for organizing care and information around patient’s needs and preferences “… the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services. The scope of care coordination is dependent on the needs and complexity of the individual.  In order to meet patient needs and deliver high-quality, high-value health care, consideration must be given to the patient’s and family’s perspectives, the healthcare professional’s perspective, and the system representative’s perspective. Key Attributes of Care Coordination Patient-centered/individualized plan of care Evidence-based care Efficiency Improved health outcomes Value-based care delivery Interprofessional team-based care Goals of Care Coordination 1. Improve and optimize care 2. Promote health and independence 3. Reduce unnecessary service utilization Everyone will need some form of health care coordination at some point in their lives Care Coordination Models Integrated Community- Models Based Models Community-Based Models Community-based care coordination is a model of healthcare that focuses on coordinating and delivering services to individuals within their community, with the goal of improving health outcomes and overall well-being. It involves collaboration among healthcare providers, social service organizations, and community resources to address the diverse needs of individuals and promote better coordination of care. Aims to enhance access to care, improve health outcomes, and reduce healthcare costs by providing comprehensive, patient-centered, and community-focused services. Key Features of Community-Based CC Holistic approach: The model recognizes that individuals' health is influenced by a variety of factors, including social determinants of health (such as housing, education, employment, and access to resources). It takes a holistic approach by addressing both the medical and non-medical needs of individuals, aiming to improve their overall health and quality of life. Care coordination: Community-based care coordination involves the coordination and management of healthcare services across different providers and settings. It ensures that individuals receive the necessary care, treatments, and support services in a coordinated and efficient manner. Care coordinators, often working in interdisciplinary teams, help individuals navigate the healthcare system, connect them with appropriate resources, and facilitate communication among healthcare providers. Community engagement: The model emphasizes engaging the community and leveraging local resources to support individuals' health needs. This may involve partnering with community organizations, such as nonprofits, faith-based groups, and social service agencies, to provide a wide range of services and support, including health education, transportation assistance, housing support, and mental health services. Key Features of Community-Based CC Patient-centeredness: Community-based care coordination is grounded in patient-centered care, where individuals' preferences, values, and goals are respected and incorporated into their care plans. It involves active communication and shared decision-making between patients, their families, and the care team, empowering individuals to actively participate in their care and make informed choices. Data sharing and information technology: Effective use of information technology, such as electronic health records and secure data sharing platforms, enables seamless communication and information exchange among different stakeholders involved in community-based care coordination. This facilitates care coordination, reduces duplication, and improves the continuity of care. Integrated Models Integrated care coordination is a model of healthcare that aims to improve patient outcomes by facilitating collaboration and communication among various healthcare providers and organizations involved in a patient's care. It involves the integration of medical, behavioral, and social services to provide comprehensive and coordinated care. By implementing an integrated model of care coordination, healthcare systems strive to improve patient outcomes, enhance patient satisfaction, reduce healthcare costs, and optimize resource allocation. It enables a more patient-centered and efficient approach to healthcare delivery, particularly for individuals with complex or chronic conditions. Key Factors of Integrated CC Comprehensive assessment: A thorough assessment of a patient's medical, psychological, and social needs is conducted to develop a holistic understanding of their healthcare requirements. Care planning: A care plan is developed based on the assessment, taking into account the patient's goals, preferences, and available resources. This plan outlines the necessary interventions and services required to meet the patient's needs. Care coordination: Care coordination involves facilitating communication and collaboration among different healthcare providers involved in the patient's care. This includes sharing information, coordinating appointments and referrals, and ensuring that services are delivered in a timely and efficient manner. Key Factors of Integrated CC Continuity of care: The integrated model emphasizes the continuity of care throughout the patient's healthcare journey. This involves ensuring smooth transitions between different healthcare settings, such as hospitals, primary care clinics, specialists, and community-based services. Patient empowerment: The model recognizes the importance of involving patients in their own care. It promotes shared decision-making, patient education, and self-management strategies to empower patients to actively participate in their treatment and make informed choices. Information technology: Effective use of information technology, such as electronic health records and secure communication platforms, plays a crucial role in supporting integrated care coordination. It allows for the seamless exchange of information among healthcare providers, reducing duplication and improving efficiency. Collaborative Learning Activity Take 5 minutes to brainstorm together in small groups… Discuss: 1. The benefits and challenges of each care coordination model 2. What population of patients might benefit from this model? Barriers to Effective Care Coordination § Limited access to social, behavioural and medical resources § Deficient knowledge § Client nonadherence to care plan To overcome these barriers, nurses can: Assess and address reasons for client non-adherence Assess for the availability of resources and incorporate this information into the care plan Assess, address, and support knowledge deficit Discharge Planning The responsibility for discharging a patient from the hospital typically lies with a team of healthcare professionals, including physicians, nurses, and other members of the care team. While the specific roles and processes may vary depending on the healthcare facility and the patient's condition, the discharge process typically involves the following: Attending Physician The attending physician, who has been primarily responsible for the patient's care during their hospital stay, plays a crucial role in the discharge process. They assess the patient's condition, review the treatment plan, ensure that the patient is medically stable for discharge, and provide necessary instructions for post-discharge care. Nursing Staff The nursing staff, particularly the discharge nurse or a designated member of the nursing team, is involved in the practical aspects of preparing the patient for discharge. They coordinate with the physician and other healthcare providers to ensure that all necessary documentation, prescriptions, and instructions are in place. They may also provide education to the patient and their family regarding post-discharge care and medication management. Care Team The care team, consisting of various healthcare professionals involved in the patient's care, collaborates to ensure a smooth and safe discharge. This may include specialists, therapists, social workers, case managers, and other allied health professionals. They contribute their expertise and coordinate any necessary referrals or follow-up appointments. Patient & Family The patient and their family play an active role in the discharge process. They need to communicate their understanding of the treatment plan, follow-up appointments, and any instructions given by the healthcare team. They should provide necessary information about the patient's home environment, support system, and ability to manage their care after discharge.  It is important to note that the discharge process is a collaborative effort involving multiple stakeholders, with the primary focus on ensuring the patient's safety and smooth transition from the hospital to their home or an appropriate care setting. Effective communication, coordination, and patient education are key elements of a successful discharge process. When does discharge planning begin? The RN Role in Care Coordination The nurse must utilize skills in comprehensive assessment to inform creation of the patient care plan and to assist in goal setting (assessment skills) Patients must be taught how to self-manage their chronic conditions with a special emphasis on medication management (patient teaching) When care coordination programs are implemented, the nurse must be able to guide structure of the intervention and implementation, followed by program evaluation to show both improved quality of patient care and assessment of healthcare utilization with associated costs. The nurse will utilize information technology to enhance communication among the interprofessional healthcare team members as well as between the patient and healthcare team. Necessary skills of care coordinator also include effective management, having variety of communication styles in order to effectively lead and work with interprofessional healthcare teams Care coordinators must have a working knowledge of health insurance and various methods of payment The care coordinator should also possess basic skills in research and evaluation so as to be able to justify the role as well as contribute to the body of science by disseminating findings of program outcomes Exemplar: Special Needs Children Ideally, these children will have access to a pediatrician/pediatric medical home with access to a full interdisciplinary healthcare team to help coordinate their needs and reduce fragmentation Social workers to connect patients to benefits and resources Pharmacists to provide medication reconciliation Dieticians to assist with nutritional needs Patient advisors to help implement collaborative goals Common conditions: Cerebral Palsy, Down syndrome, Autism, congenital abnormalities, Cystic Fibrosis, Epilepsy, intellectual disabilities Exemplar: Frail and Older Adults The frail and elderly population spend the most healthcare $ per capita Vulnerable to negative health outcomes after falls and serious illnesses, making this population ideal for care coordination Care coordination helps to prevent such events and to assist with aging in place so as to avoid unnecessary institutionalization Exemplar: Chronic Illness Examples: cancer, stroke, heart failure, COPD, diabetes, TBI Require an individualized discharge summary, medication reconciliation, post-discharge phone call/follow-up, timely primary care and specialist follow-up Goal to reduce readmission and to empower patients Exemplar: Mental Illness Integrated care is (unfortunately) lacking in the primary care setting Needs a multidisciplinary team approach that focuses on preventing and treating chronic conditions, purposeful connection to community resources to address social determinants of health, and to ensure there is financial stability Self-management support Exemplar: EOL Care Encompasses physical, psychosocial, spiritual, and cultural needs of both the patient and family Hospice and palliative care can take place in *all settings* - including at home Multidimensional and interprofessional approach to improve quality of care Interrelated Concepts