Continuum of Care Flashcards
What is the definition of continuum of care?
- integrated system of care
- composed of services & integrating mechanisms* which guide/track person(s) over time
- utilizing comprehensive array of physical/mental health & social services
- spanning all levels of care intensity (high acute to low acute)
- ensures that pt’s leaving the hospital receive comprehensive care once home, care doesn’t just stop once they leave the hospital
- A series of initiating, continuing and concluding care events that result when pt’s seeks providers in one or more environments in the healthcare system
What are three major factors driving healthcare reforms, and consequently, continuum of care?
1) Decreased length of hospital stay (LOS)
2) Movement towards more home care/community care (i.e. emphasis on family involvement; recognized need for collaborative partnerships)
3) Regionalization (spreading out of care geographically; impact on concept)
What are the goals of continuum of care?
1) Provide seamless care from hospital to home/community
2) Patient/family understands what to expect at each stage of illness and interaction with health care system
3) Maintenance of quality and continuity of pt care in the changing healthcare environment (aim to live and access care in the community)
What are the key elements of continuity of patient care?
- refers to personalized, continuous care
- begins at point of entry into healthcare system (begin discharge work on admission)
- continues until patient’s health-related problems / needs resolved by means of
- interpersonal
- interdisciplinary
- collaboration & communication
- focus on patient / family
Describe the emergence of regionalization:
There used to be 20 different health authorities in B.C., but over the years i has been downsized to six (five geographical, one specialty): Northern, Interior, VIHA, Vancouver Coastal and Fraser Health Authority, plus one provincial specialty services (ex. BC Children’s, BC Women’s, BC Cancer Agency)
What are the goals of regionalization?
- Look at unique health care needs of the community
- Integration of continuum of care concept
- Reduction in agency centered-ness (ex. cost effective/resource efficient to achieve goals)
- Promotion of pt centered care through development of inter-disciplinary teams
- Promote collaborative care between agencies
- Improve communication between acute care agencies/community agencies to provide continuity of pt care (ex. from home to hospital to home)
What is involved in discharge planning?
Nurses play an essential role in helping pt’s/family members make a successful transition from hospital to home, and plan for an effective discharge
What is the three stages of discharge planning in relation to the role of the nurse?
STAGE ONE: Nurse’s role, as first point of contact, is to do a holistic admission assessment and caregiver assessment (home environment, social support, pt preference, etc.) (“getting to know the patient”).
STAGE TWO: Nurse as patient advocate (since you know the pt best compared to other HCP’s). Involve other HCP’s in plan, and estimate initial discharge date.
STAGE THREE: Nurse’s role in contacting the community team and gathering necessary information for community referral forms. Helping the patient prepare to go home, ultimately.
STAGE FOUR: making the transition; involves home health nurse, pt, family caregiver, other community members as appropriate; an effective discharge determined by if it supports the 5 standards of Community Home Nursing Care (CHNC)
What are the components of effective discharges?
- Occurred in stages
- Inter-professional collaboration (trust, blurring boundaries, leadership)
- Sufficient timing of provision and receipt of information
- Clear communication (team, pt/family, community)
- “Close the loop” and “fill the picture”
What are barriers to discharge planning?
- Time constraints (do you have days or months to plan a discharge?)
- Cost
- Availability of HCP’s for care continuity
- Paternalistic attitudes
- Communication gaps
- Insufficient resources for need
- Lack of family caregiver involvement
- Unclear consideration of home environment
What are the benefits to effective discharge planning?
- Improved quality of care
- Ease pt fears and insecurities
- Improved pt outcomes
- Decreased length of hospital stay
- Appropriate/timely referrals
- Decreased duplication of services, post-hospital complications and re-admissions to hospital
- For the HCP’s, it heightens awareness of resources, decreases frustration and is a more efficient use of professional time
What is the definition of home health according to fraser health?
- Programs and services work in tandem with other parts of the health care system
- To provide people with the right services at the right time and in the right environment to meet their health care needs.
What are the four key objectives for delivering home health services?
- Provide the support necessary for clients to remain in their own homes for as long as possible
- Provide at-home services to clients who would otherwise require admission to hospital
- Provide assisted living and residential care services to clients who can no longer be effectively supported in their own homes
- Provide End of Life Care
What is the home health philosophy?
committed to promoting the - well-being, dignity and independence of clients and their families.
- aims to supplement (not replace) and complement care provided by individuals, families and communities.
What are principles that guide the philosophy of home health care?
- Clients /families should have information needed to make decisions about lifestyle/care.
- Services will complement/supplement not replace individual’s efforts to care for selves with assistance from family/friends/community
- Clients have right to make own care decisions including right to ‘live at risk’
- HHC services will promote the well-being, dignity and independence of clients
