Chapter 5 Patient Centered Care Planning Flashcards
Definition of patient and family-centered care
An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.
What elements are included in comprehensive needs assessment?
PHQ-9 Functional Assessment Cage and Cage-AID Mini-Cog Modified Caregiver Strain Index Get Up and Go Test PAM-Pt Activation Measure, gauges the knowledge, skills and confidence essential to manage one's own health and healthcare
Pre-visit Chart Review and Visit Planning to Identify Gaps in Care and Individualize the Plan Focus
- Last seen by PCP
- Missed appts?
- Last prev care visit over 13 mo?
- Preventive care UTD?
- Had an A1C <7% in last 6 months?
- Most recent biometric data is . . .
- BMI is . . .
- Meds up to date?
When should you examine the chart prior to PCP appt?
24-48 hrs
a. Recommended screenings
b. What’s outstanding?
c. Pending tests?
d. Vaccines UTD?
e. Specialist appts needed (db eye exam)
f. Abnormal labs to f/u?
g. Pattern of missed appts?
h. AD, health care proxy, durable POA?
i. Need caregiver, housing assistance?
Visit planning: do this in advance to f/u outstanding test results, prev care, PCP orders are obtained prior to visit
a. ID missing labs results outside lab
b. Reports outside ophth, endo, discharge
summary, dentist
c. Missing labs, xrays, immunizations
d. Notify pt of outstanding labs, xrays etc
and schedule
e. Have AD available for visit
f. Have screening tools available for visit
Gaps in care include what?
a. Missed appts - ask why missed (barriers)
b. No recent lab work to monitor
progression of chronic disease
c. Discharge and pharmacy
1. Meet with multidisciplinary team
throughout discharge process
2. Ensure inpt case mgmt and SW
included in plan
3. Ensure PCP aware of discharge plan
4. Family and caregivers understand plan
5. Care Plan easily accessible
6. Care Plan updated as needed
Risk Stratification
Meets high-risk criteria if: -unstable -needs psychosocial support -no access to med -increased ED and hosp use IF HIGH RISK BUT NEEDS ARE MET . . . coordinate the following. -caregiver support -community resources or ancillary services -primary care and specialty medical management -psychosocial support -pharmacy support
Barriers to patient engagement
- Mental Illness
- Low motivation
- Time constraints for providers
- Not ready to change
- Insufficient provider training of RN in CCTM new role
- Illness or pain
- Functional deficits
- Substance abuse
- Low health literacy (education)
- Religious beliefs
- Culture differences
Motivational Interviewing - utilize
Pay specific attention to the language of change
Plan of Care Assessment includes:
- Vitals
- Ht, wt, BMI
- Pain score
- Risk assessments:
Pt safety
Fall risk
Functional status
Mini-Cog
PHQ-9
Get Up and Go
Tobacco hx
Sexual history
Caregiver strain
Abuse
Neglect
Med Review
Reconcile all meds and OTC
DME
All care devices and current readings
Diet
Note special or restricted
Complaints or concerns
Note them
Psychosocial assessment
- living situation
- community services currently used
- exercise or activity
- sleep routine
- trouble voiding or moving bowels
- dental issues
- swallowing issues
Advance Directives
Give at next appt
Immunization Hx
Review and arrange
Any support groups involved with?
AA, NA, Nutrition Support Group, Cottage
Referral to specialists needed?
Pend orders/order per protocol
Goal setting
Agreeable to pt and/or caregiver. Goals are pt driven, not provider
Patient Communication With Providers, Family and Friends
See list on page 52 for examples re:
- Communication
- Coping and relaxation
- Healthy eating and wt mgmt
- Medication management
- Pain, fatigue and sleep goals
- Personal safety
- Problem solving
- Self-monitoring
Agree on specific date and time for f/u
Leave pt with: 1. Action Plan 2. F/U appts booked 3. Culturally specific, literacy based education 4. Who to call for questions 5. F/U community services 6. Call CM/Clinic before going to ED 7. Updated med list 8. Have all meds filled on time 9. Pt will teach-back all new learning 10. Document pt's understanding through "teach back" and any areas of need for review.
Multidisciplinary Care Plan needs to include:
-regular communication
-pt problems linked to mutual goals
-outcomes that document progress toward
goal
-evidence-based interventions that align
with assessment and treatment
-education to prepare pt and family for
transitions in care
Role functions is complex, The Advisory Board created a “Staff Audit Tool” to be used as a framework for deploying the most appropriate site-specific resources to meet pt needs
- In pt navigator/case manager - primary contact for providers and other care providers, care plan and discharge planning
- Transition partner - follows pt from hosp to home, transition coach
- Nonurgent ED navigator - connects pts
to clinic - Clinical pt guide, (catastrophic illness i.e. cancer dx
- Co-morbidity chronic care coordinator/high risk outpt care manager: THIS IS THE ROLE OF THE RN IN CCTM.
- Disease specific chronic care coach: RN IN CCTM
- Outpt care coach: ambulatory care nurses promote disease mgmt, prev care and wellness, remote monitoring,