NUR460-Week 2.docx

**[Week 2 -- Medical Complexity ]** **CMC: A Definitional Framework** - Children with medical complexity have more than 1 chronic condition multi morbidity, and usually multi systemic issues (ex. Heart and feeding issues) - Relying on technology for support or for treatments (eg....

**[Week 2 -- Medical Complexity ]** **CMC: A Definitional Framework** - Children with medical complexity have more than 1 chronic condition multi morbidity, and usually multi systemic issues (ex. Heart and feeding issues) - Relying on technology for support or for treatments (eg. NG tube, pacemakers) - Frequent flyers require specialized care and require care from multiple HCPs - Inc caregiver and service requirement in the community and home setting Inc social and financial burden **Healthcare challenges for CMC** - - Poor communication between healthcare staff - Fragmented care - Multiple providers - Poor health outcomes - Frequent hospitalizations - Increased risk for medical errors - Inequitable resources and available services - More reactive care vs. anticipatory and preventative care - Limited family and community supports - Parents are forced to become healthcare navigators - Economic burden and constant care needed **Common medical concerns for CMC** - CNS -- seizures, pain, hypertonia, movement disorders, sleep issues - ENT -- vision/hearing impairments, secretions, obstructive/central apnea - RESP -- need for support (O2, CPAP/BIPAP, trach, suction, cough assist), pneumonias - CVS -- Arrhythmias, dec cardiac function - GI -- GERD, emesis, constipation, diarrhea - Growth/Nutrition -- enteral or parenteral feeds, feeding safety (aspiration), weight gain/loss - GU -- UTIs, nephrolithiasis - Endocrine -- precocious/delayed puberty, osteopenia - MSK -- scoliosis, contractures, hip subluxation, fragility fractures - Derma -- pressure sores, dermatitis **Understanding the whole picture** - Requires holistic approach - It is important to know caregiver decision making generally follows what they perceive as inc QoL - Inc financial and social demands for caregivers - Split dynamic between parents -- one parent is usually more invested medically - Leads to inc stress and demands inc rate of divorce - Need to understand overall goals form medical care -- assess family care goals, CPR, etc. **From Chaos to Streamlined Care** - Having multiple different teams disjointed care - Care coordination and communication between services is important - Ensuring continuity of care - Identifying a care coordinator is important -- someone needs to take on the role increased satisfaction for families **CCKO -- Complex Care Kids Ontario** - Standard operational definition for children with medical complexity who are medically fragile and/or technology dependent - Under 18 years of age and meets at least one criterion from EACH of the following four conditions - Technology dependent and/or users of high intensity care - Fragility - Chronicity - Complexity **Care Plans** - Outline major issues and medical complexities - Medical passports can be given to all care providers - Look up care plan for valuable info when dealing with a complex pt **Complex health and social care needs** - 6 areas of vulnerability - Pt with 2 or more elements or major vulnerability in one of the 6 areas is considered as having complex needs A diagram of a diagram of a variety of colors Description automatically generated with medium confidence **Summary of Article: Care coordination activities** **Activities Targeting Patients, Families, and Caregivers** - **Identify Beneficiaries**: Collaborate with general practitioners to identify patients with complex needs or high healthcare expenditures and invite them for intervention. - **Assess Needs and Goals**: Evaluate comprehensive patient, family, and caregiver needs and goals, including caregiver burden. - **Develop Tailor-Made Care Plans**: Create personalized care plans with patients; ensure plans are updated, accessible, and communicated to all involved professionals. Educate patients on care coordination efforts. - **Provide Direct Care**: Follow guidelines for disease risk reduction, monitor health status, conduct basic screenings, and manage symptoms and concurrent chronic conditions. - **Monitor and Respond to Changes**: Track symptoms, medications, clinical results, and emergency events; adjust care plans as needed. - **Establish Relational Continuity**: Build trust-based relationships, advocate for patients, and serve as the main contact person. - **Plan End-of-Life Care**: Identify advance directives, inform patients of their rights, and assist with end-of-life planning and emotional support. - **Support Activation and Empowerment**: Encourage patient involvement in care, support self-management and adherence, and facilitate navigation of healthcare and community resources. **Additional Activities for Patient and Family Support** - **Education and Counseling**: Provide individualized education and counseling. - **Support Self-Management and Adherence**: Help patients manage their conditions and adhere to treatment plans. - **Emotional and Psychological Support**: Offer support for emotional and psychological well-being. - Support groups, speaking with someone who has been through it, online virtual support, providing 1 on 1 care from nurse to pt - **Technical and Administrative Support**: Assist with monitoring biological parameters and administrative tasks. **Activities Targeting Health and Social Care Professionals and Services** - **Clarify Roles and Responsibilities**: Define roles, negotiate responsibilities, and ensure shared accountability among professionals. - **Exercise Leadership**: Build relationships, offer local knowledge, and facilitate interdisciplinary care approaches. **Activities Linking Patients with Care Professionals and Services** - **Coordinate Community Resources**: Arrange access to community resources and provide guides to social and welfare services. - **Coordinate Within Healthcare Teams**: Organize case reviews, team meetings, and referrals; assist with appointment preparation and patient navigation. - **Facilitate Care Transitions**: Coordinate care during transitions, including hospital discharges, and update care plans accordingly. **Cross-Cutting Activities Related to Communication** - **Open Communication with Patients**: Engage in honest discussions about health and care. - **Interprofessional Communication**: Clarify roles, responsibilities, and shared accountability with other professionals. - **Information Transfer**: Communicate and document care plans and patient information accurately and timely. **Discussion** - **Central Role of Nurses**: Nurses play a critical role in care coordination for patients with complex needs, contributing significantly to improving care and outcomes. - **Model Flexibility**: The proposed model of care coordination is flexible and should be tailored to specific patient needs and contexts. - **Intensity and Frequency**: Higher intensity and frequency of activities are necessary for patients with complex needs compared to those with less complex conditions. - **Relational Continuity**: Maintaining a continuous and trusting relationship with patients is crucial for effective care coordination. - **Importance of Home Visits**: Home visits are vital for understanding patient needs and planning appropriate care. **Implications for Research and Practice** - **Fidelity and Capacity Building**: Future research should assess the fidelity of interventions and the need for capacity building in less frequently performed activities. - **Classification of Activities**: Establish a classification of activities based on their efficacy and resource consumption. - **Professional Roles**: Further research could clarify the specific contributions of different professionals in care coordination. - **Co-location Benefits**: Co-location of health and social care professionals enhances teamwork and integrated care. - **Documentation and Recognition**: Develop systems to document care coordination activities for financial and societal recognition. **Strengths and Limitations** - **Strengths**: Comprehensive synthesis of nursing care coordination activities; valuable insights validated by a patient-research-partner. - **Limitations**: Lack of comparison between interventions; potential missing details due to variability in study descriptions. **Conclusion** - **Variety of Interventions**: Multiple interventions are used for care coordination, requiring a high frequency and intensity of activities. - **Continuity of Care**: Ensuring availability and continuous support enhances care coordination. - **Model Development**: Primary care models should support multidisciplinary teamwork and integrate care effectively while balancing efficiency and intensity. **Integrated Health Care System** - Move from a fragmented to a more integrated healthcare system - Need to be able to coordinate care within the community and across all care levels - Integrated care has the potential to improve: - Continuity of care - Accessibility - Quality and safety of care - Cost effectiveness of services - Look at the pt more holistically and ensure close-loop communication **Models of integrated care** - For integrated care to be successful -- care coordination is essential - Lack of global consensus on a single model, but all agreed to care coordination, but it can take place in many ways - No single conceptual model or framework - Variety of approaches: - Case management - Pt navigation - Collaborative care - Disease management - Care management - Chronic care model **Effective care coordination** - Involvement of a multidisciplinary primary care team that functions cooperatively and cohesively to provide the right care in the right place at the right time - The role of care coordinator can be undertaken by professionals from various backgrounds: nursing, social work, OT, PT - It could be team-based model of care coordination (e.g., nurse and social worker) - Choice of CC should take into consideration contextual factors, the population of interest and the goals of the program - Could be an exclusive or combined role (combined with wider team management responsibilities or with clinical provision of care) **Nurse-led care coordination** - Improves access to appropriate treatment - Reduces costs - Improves clinical outcomes - Improves quality of care - Improves communication between staff - Increases safety of vulnerable patients during transition - Reduces unplanned readmissions - Reduces medication errors, or errors that were made d/t lack of education **A model of nursing care coordination for medically complex patients** - Three categories - Activities targeting pt and family - Activities that link pt with services and MDT - Activities that target MDT - Note interrelation between these categories - Thinking of what works for pt at home and gradually shift our care to match that so they can be prepared for the same care at home - Adapt to their schedule **What is your role in caring for medically complex patients?** - Support treatment and connection - Continuity, expertise in practice area, system navigation - Great opportunity to support goal setting, joint decision making, partnership, have discussions about goals of care and advance care planning - Families look to us for medical expertise, support, guidance and a partnership