Continuum of Care Flashcards
What is the definition of continuum of care?
- Integrated system of care
- composed of services and integrating mechanisms which guide/track person(s) over time
- utilizing comprehensive array of physical/mental health and social services
- spanning all levels of care intensity
What are the 3 major factors driving continuum of care?
- decreased length of hospital stay (LOS)
- movement towards more home care/community care
- regionalization - impact on continuum of care concept
Define “integrate”
Integrate means to combine parts to form a whole.
What are three goals of continuum of care?
Provide seamless care from hospital to home/community.
Patient/family knows what to expect at each stage of illness/interaction with Health Care system.
Maintenance of quality and continuity of patient care in the changing healthcare environment.
What does “continuity of patient care” refer to?
Refers to personalized, continuous care.
Where does continuity of patient care begin?
Begins at point of entry into the health care system
When does continuity of patient care end?
Continues until patient’s health-related problems/needs resolved.
What are some means of resolving patients’ health-related problems/needs?
Interpersonal
Interdisciplinary
Collaboration and communication
Focus on patient/family
When did regionalization emerge as a concept in healthcare?
Regionalization concept emerged out of the 1993 “New Directions for Healthy BC” report.
do not need to memorize this date for exam
What are some goals of regionalization?
Look at unique health care needs of the community
integration of Continuum of Care concept
reduction in agency centeredness
promotion of patient-centered care through development of inter-disciplinary teams
promote collaboration of care between agencies
Improve communication between acute care agencies / community agencies to provide Continuity of patient care
When does discharge planning begin?
Discharge planning begins upon patient’s admission.
What occurs during stage 1 of discharge planning? (Nurse’s role)
Nurse’s role as first patient point of contact with hospital patient:
- admission assessment/”getting to know the patient”
- caregiver assessment
What occurs during stage 2 of discharge planning? (Nurse’s role)
Nurse as patient advocate:
- involving other HCP’s in the plan
- initial discharge date
What occurs during stage 3 of discharge planning? (Nurse’s role)
“getting ready to go home”
Nurse’s role in contacting the community team
What occurs during stage 4 of discharge planning? (Nurse’s role)
Making the transition.
Involves Home Health nurse, patient, family carer
What are some components of an effective discharge?
Occurred in stages
Inter-professional collaboration( trust, blurring boundaries & leadership)
Sufficient timing of provision and receipt of information
Clear communication-> Circles of communication ( Team, PT & Family, community)
“Close the Loop” and “fill in the picture”
What are some barriers to discharge planning process?
- Time available + timely info (4d - 2m) discharge
- cost
- availability of HHCNs/care continuity
- paternalistic attitudes
- “chopping and changing”
- communication gaps
- insufficient resources for need e.g. 21 h for 2 person transfer; pain management.
- lack of family caregiver involvement
- unclear consideration of home environment
What are “paternalistic attitudes”?
Old-school idea that the doctor/nurse knows best and they tell the patient what to do and make all the decisions.
What is “chopping and changing”?
Changing nurses/hospitals/doctos
What are some benefits to continuum of care to the patient/family?
- improved quality of care
- ease patient/family fears and insecurities
- improved patient outcomes
- decreased length of hospital stay
- appropriate/timely referrals
- decreases duplication of services
- decreases post-hospital complications
- decreases rate of hospital re-admissions
What are some benefits of continuum of care to health care professionals?
- heightened awareness of resources
- decrease in frustration
- more efficient use of professional time
What is the definiton of home health care?
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 4 key objectives that guide the delivery of 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 the 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?
Home health is committed to promoting the well-being, dignity and independence of clients and their families. Home Health Care division aims to supplement (not replace) and complement care provided by individuals, families and communities.
