Care Coordination Flashcards
What are the goals of care coordination?
- Facilitate the appropriate delivery of the necessary services and information to support optimal health care across settings and overtime.
- Improve and optimize care
- Promote health and independence
- Reduce unnecessary service utilization
Who develops the plan of care?
The nurse works with the patient to develop the plan of care that addresses both health and personal needs
Who should be on a multidisciplinary case team conference?
All the health care staff that is directly involved in the client’s care (Family can also attend)
Who should be involved in a patient’s plan of care?
the patient, the multidisciplinary team, and the family
What is the social model of care coordination?
A model that addresses home and community-based services but does not address medical care
What is the medically oriented model of care coordination?
Coordinate medical services that are designed for a specific diagnosis
True or False: Provider orders are considered integrated models
False: They are considered medically oriented models because they relate to a specific diagnosis
What are integrated models of care coordination?
Include social support, and community clinical and nonclinical services
Define the Patient-Center Medical home model
A patient’s primary care provider works with the patient and family to develop a personalized plan that addresses the patient’s physical and mental health needs across the lifespan
What are the duties of the RN as a case manager?
- coordinate all aspects of care
- Advocate for patients at each stage of care
- plan an overall strategy to address each patient’s problems
- Assess the patient’s needs
- ensure that the patient’s independence and quality of life are maximized
- Explore resources
- Identify challenges: religious practices, cultural beliefs and practices
