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NUR136 Care Coord
Care Coordination and HC Org
| Term | Definition |
|---|---|
| Care coordination | et of activities purposefully organized by a team to facilitate the appropriate delivery of the necessary services and information to support optimal health and care across settings and over time. |
| Goals of Care Coordination | Improve and optimize care. Promote health and independence. Reduce unnecessary service utilization. |
| 5 Key Attributes to Care Coordination | Communication Proactive Plan of Care Target Activities Proactive Follow up Interprofessional Teamwork |
| Greatest Care Giving Needs | Vulnerable populations Individuals with multimorbid chronic conditions Children and older adults |
| Social Models | Manage home- and community-based services. Do not address medical care. |
| Medically Oriented Models | Coordinate medical services. Some focus on a specific diagnosis. Some focus on the coordination of multiple treatments for multiple conditions. |
| Integrated Models | Combine health care (both acute and long-term), social support, and community services. Emphasis is on holistic, patient-centered, family-focused care. |
| Nursing in Client Discharge | Assist as needed in notifying family or significant other Collect patient belongings Prepare patient for the ride home or to a new facility |
| Discharge to Skilled Nursing | information regarding treatments, medications, special needs RN completes a patient information sheet ;Information recorded 1&2 diagnoses; current orders; medications;provider information; brief synopsis of hospital stay. |
| Home Healthcare Benefits | reduced cost, decreased exposure to potentially serious infections, and, most important, provision of care in a familiar, comfortable environment. |
| AMA Steps | informed of additional potential consequences. include receive prescriptions for medications or treatment, if insurance refuse to pay the hospital bill, will be liable. Document that you relayed this information in the medical record. |
| Physicians Role in Death | Patient must be pronounced dead by a physician |
| Autopsy | usually performed when a patient has died of unknown causes, has died at the hands of another person, or has not been seen by a physician within a specified period of time. |
| palliative care | reduce or relieve the symptoms of a disease without attempting to provide a cure |
| hospice | help patients in the end stage of life, and their families, to experience the process of death with the highest quality of life and least amount of disruption as possible. |
| common experiences when facing death | loss, grief, mourning, bereavement |
| Stages of Grief | Denial Anger Bargaining Depression Acceptance |
| Pain Management at End of Life | regularly scheduled pain medication regimen, augmented with PRN (as needed) medications when regularly scheduled pain medications are inadequate to achieve pain control |
| Respiratory distress | considered extreme suffering, and it requires an aggressive treatment |
| Physical changes as death approaches | pulse increases and becomes weaker or thready Blood pressure declines skin of the extremities becomes mottled, cool, and dusky Respirations become shallow and irregular |
| Cheyne-Stokes respirations | respirations that gradually become shallower and are followed by periods of apnea |
| Priority interventions for grieving | focus on providing an environment that allows the patient and family to express feelings |
| Five Wishes | Helps the patient communicate the care they want to the healthcare team and family |
| Case Manager Home Health Responsibility | admitting the patient, establishing the plan of care (including visit frequencies), and coordinating the efforts of other disciplines |
Created by:
susan.martin
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