week 9: care coordination Flashcards
what is the geriatric program assessment team (goal, access, service)
goal: efficiently facilitate services meant to reduce likelihood of ER visit for older adult
access: anyone
service: comprehensive assessment of older adult by physician
they will have GP follow up
what is PRIME
Goal: keep older adult who is eligible for long term care at home for longer
service: case coordination
this is a one stop service where all the needs of the older adult are addressed
what is the rehabilitation outreach team
access: anyone, but mainly for older adults with failing functioning
intervention: reccomend
coordination with other services: physician, homeware, rehab
what is the healthy aging resource team
access: anyone, but mainly the older adult coping within the community
coordination: primary health
what is day hospital
access: hospital, homeware, rehab outreach
who is home care for
anyone, but mainly older adult with some functional decline
what is Alzheimers society first link
access: physician referral for anyone living with dementia
what are some assessments of care needs for older adults
sensory issues
ADL
medications
safety of environment
pain
depression, anxiety, sleep issues
difficult behaviours
what are some assessments of caregiver needs
social isolation, depression, anxiety
capacity to provide care
support system
depression
legal and financial planning
relationship with older adult
what is the main intervention to improve care coordination
key is to ensure more people have a family doctor and access to community care services
what is a caregiver crisis
its a new thing thats coming soon, its a new study that shows that increasing demends on caregivers are taking a toll on their wellbeing
many are tired, overwhelmed, and depressed
more than 1 in 4 report that their mental health is really poor
what are some barriers to optimal care cordination within family dynamics
family not interested
family indecisions
perception of hopelessness
fear of failure
what is relational care
what are the four family needs that support healthy family dynamics
type of help
following information
following supplies
tell the following people about family action plan
which family stage are more than half of caregivers in
late bloomer
slide 37
what is the clinical measurement judgment model
recognise cues
analyse cues
prioritise hypothesis
generate solutions
take action
evaluate outcomes
what is the role or a nurse care coordinator
communication
advocate
understanding research and evaluation
