chap 12 interprofessional collaborative practice & care coordination Flashcards
care coordination
deliberate organization of patient care acts btwn 2 or more participants (including the patient) to facilitate the appropriate delivery of quality health care services in an efficient person-centered manner; mechanism to make sure the patients get the right care at the right time in the most efficient and cost-effective manner, by the right person in the right setting
care coordinator
care provider (nurse case manager, social worker, community health worker, or lay person) who is responsible for identifying a person’s health goals and coordinating services and providers to meet those goals
care transition
continuous process in which a patient’s care shifts from being provided in one setting of care to another
collab prac
what happens when mult health workers from diff professional backgrounds work together w patients, families, carers, and communities to deliver the highest quality of care
community-based care
health care that is provided to ppl who live w in a defined geographic region or who have common needs; designed to meet the needs of ppl as they move btwn and among health care settings
continuity of care
coordination of services provided to pts before they enter a health care setting, during the time they are in the setting, and after they leave the setting
discharge planning
systematic process of preparing the pt to leave the health care facility and for maintaining continuity of care
home health care
agency eligible to receive fed funds that provides home-based health care; may be independent, hospital operated, or health department managed
medication reconciliation
process of creating an accurate list of all medications a pt is taking, including drug name, dosage, freq, and route, and comparing the list to the physician’s admission, transfer, or discharge orders, w the goal of providing correct meds to the pt at all transition points w in the hospital
patient handoffs
transferring responsibility for a pt from 1 caregiver to another w the goal of providing timely, accurate info abt a pt’s plan of care, treatment, current condition, and anticipated changes
telehealth
use of electronic info and telecommunication technologies to provide care when the pt and the clinician are not in the same place at the same time
Healthy People 2030
defines Leading Health Indicators (LHls) for communities
IRS requires not-for-profit hospitals to conduct…
community health needs assessments for their surrounding communities to demonstrate how they are meeting their needs
Roles of C/PHN
-patient advocate
-coordinator of services
-educator/counselor
CUS (continuity of care strategy)
-I am Concerned
-I am Uncomfortable
-I believe Safety is at risk
