Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

CCTM > Chapter 5 Patient Centered Care Planning > Flashcards

Chapter 5 Patient Centered Care Planning Flashcards

1
Q

Definition of patient and family-centered care

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What elements are included in comprehensive needs assessment?

A 
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pre-visit Chart Review and Visit Planning to Identify Gaps in Care and Individualize the Plan Focus

A
  1. Last seen by PCP
  2. Missed appts?
  3. Last prev care visit over 13 mo?
  4. Preventive care UTD?
  5. Had an A1C <7% in last 6 months?
  6. Most recent biometric data is . . .
  7. BMI is . . .
  8. Meds up to date?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

When should you examine the chart prior to PCP appt?

A

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?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Visit planning: do this in advance to f/u outstanding test results, prev care, PCP orders are obtained prior to visit

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Gaps in care include what?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Risk Stratification

A 
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Barriers to patient engagement

A
  1. Mental Illness
  2. Low motivation
  3. Time constraints for providers
  4. Not ready to change
  5. Insufficient provider training of RN in CCTM new role
  6. Illness or pain
  7. Functional deficits
  8. Substance abuse
  9. Low health literacy (education)
  10. Religious beliefs
  11. Culture differences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Motivational Interviewing - utilize

A

Pay specific attention to the language of change

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Plan of Care Assessment includes:

A
  1. Vitals
  2. Ht, wt, BMI
  3. Pain score
  4. Risk assessments:
    Pt safety
    Fall risk
    Functional status
    Mini-Cog
    PHQ-9
    Get Up and Go
    Tobacco hx
    Sexual history
    Caregiver strain
    Abuse
    Neglect
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Med Review

A

Reconcile all meds and OTC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

DME

A

All care devices and current readings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Diet

A

Note special or restricted

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Complaints or concerns

A

Note them

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Psychosocial assessment

A
  • living situation
  • community services currently used
  • exercise or activity
  • sleep routine
  • trouble voiding or moving bowels
  • dental issues
  • swallowing issues
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Advance Directives

A

Give at next appt

17
Q

Immunization Hx

A

Review and arrange

18
Q

Any support groups involved with?

A

AA, NA, Nutrition Support Group, Cottage

19
Q

Referral to specialists needed?

A

Pend orders/order per protocol

20
Q

Goal setting

A

Agreeable to pt and/or caregiver. Goals are pt driven, not provider

21
Q

Patient Communication With Providers, Family and Friends

A

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
22
Q

Agree on specific date and time for f/u

A 
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.
23
Q

Multidisciplinary Care Plan needs to include:

A

-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

24
Q

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

A
  1. In pt navigator/case manager - primary contact for providers and other care providers, care plan and discharge planning
  2. Transition partner - follows pt from hosp to home, transition coach
  3. Nonurgent ED navigator - connects pts
    to clinic
  4. Clinical pt guide, (catastrophic illness i.e. cancer dx
  5. Co-morbidity chronic care coordinator/high risk outpt care manager: THIS IS THE ROLE OF THE RN IN CCTM.
  6. Disease specific chronic care coach: RN IN CCTM
  7. Outpt care coach: ambulatory care nurses promote disease mgmt, prev care and wellness, remote monitoring,
25
Q

Evidence-Based Care Resources

Government agencies

A

Treatment based on research

  • Administration on Aging www.aoa.gov
  • CDC www.cdc.gov
  • Agency for Healthcare Research and Quality www.AHRQ.gov. Pt safety and quality: An evidence based handbook for nurses.
26
Q

Evidence-Based Care Resources

Nongovernmental sources on evidence based practice

A
  • Institute for Healthcare Improvement www.ihi.org
  • Hartford Institute of Geriatric Nursing
    www. hartfordign.org
  • NICHE (Nurses Improving Care for Health system elders www.NICHE.org
  • American Geriatric Society
    www. americangeriatrics.org
27
Q

How to utilize the sources on evidence based practice . . .

A

Google best evidence-based practice for your problem and preferably your pt population, you will find latest evidence-based guidelines that may not be in library databases

28
Q

Monitoring and measuring pts for progress and early signs of exacerbation/increased facility utilization

A

-period assessment of pt’s need for care and care coordination. (p55)

29
Q

Red Flags when monitoring pt progress

A
  1. Hosp re-admissions including all-cause 30 day re-admissions
  2. Increased complications associated with disease process (new kidney disease associated with uncontrolled db)
  3. Missed appts (hosp f/u with specialist after new dx HF)
  4. Underutilized rxs, missesd refills
  5. Frequent ED visits
  6. Frequent falls
30
Q

Quality Measures and Outcomes - need structured monitoring to measure RN CCTM and pt performance

A

a. Close collaboration with pt
b. Incremental goals and monitoring pt progress via process and outcome indicators imbedded in nursing documentation
c. Measure are tracked utilizing HEDIS (Health Effectiveness Data and Information Set), used by more than 90% America’s health plans to measure performance (colo rectal, breast cancer, Chlamydia screening)

31
Q

Communicating the Plan of Care

A

Care plan should be available to all care providers to observe in ER. RN to communicate changes, pt should have a copy of most recent care plan with them at all times

CCTM (6 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions