Chapter 14

1. Chapter 14 Organizing Patient Care

2. The Primary Means of Organizing Nursing Care for Patient Care Delivery • Total patient care • Functional nursing • Team and modular nursing • Primary nursing • Case management

3. There is no one “best” mode for organizing patient care. Many of the newer models of patient care delivery systems are merely recycled, modified, or retitled versions of older models Organizing Patient Care

4. Changing the Patient Care Delivery Mode—Questions the Change Agent Must Ask • How will the reorganization alter autonomy and individual and group decision making? • How will social interactions and interpersonal relationships change? • Will employees view their unit of work differently? • Will the change require a wider or more restricted range of skills and abilities on the part of the caregiver? • Will the redesign change how employees receive feedback on their performance, either for self-evaluation or by others? • Will communication patterns change?

5. Total Patient Care or Case Method Nursing • It is the oldest mode of organizing patient care • Nurses assume total responsibility for meeting the needs of all assigned patients during their time on duty • It is sometimes referred to as the case method of assignment because patients may be assigned as cases • It is still widely used in hospitals and home health agencies

6. Diagram of Total Patient Care

7. The greatest disadvantage of total patient care delivery occurs when the nurse is inadequately prepared to provide total care to the patient Disadvantage of Total Patient Care

8. Functional Method of Nursing • Evolved as a result of World War II • Uses relatively unskilled workers who have been trained to complete certain tasks • Care is assigned by task rather than by patient

9. Functional Nursing Structure

10. A major advantage of functional nursing is its efficiency; tasks are completed quickly, with little confusion regarding responsibilities However, functional nursing may lead to fragmented care and the possibility of overlooking patient priority needs Advantages and Disadvantages of Functional Nursing

11. Team Nursing • Ancillary personnel collaborates in providing care to a group of patients under the direction of a professional nurse • It requires extensive team communication and regular team planning conferences • It allows members to contribute their own special expertise or skills • Disadvantages are associated with improper implementation rather than the philosophy itself

12. Team Nursing Structure

13. Modular Nursing • Modification of team and primary nursing • Similar to team nursing, but uses a smaller team • Pairs professional nurses with ancillary staff to deliver care to groups of patients • Used frequently during the 1980s and 1990s

14. Primary Nursing/Relationship-Based Nursing • It uses some of the concepts of total patient care • It brings the nurse back to the bedside to provide clinical care • It can succeed with a diverse skill mix just as team nursing or any other model can succeed with an all-RN staff • Job satisfaction is high; however, this method is difficult to implement because of the degree of responsibility and autonomy required of the nurse • Disadvantages lie primarily in improper implementation

15. Case Management Nursing • Collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes • It coordinates care through an episode of illness • The focus is on individual clients, not populations of clients • Some feel that the role of case manager should be reserved for the advance practice nurse or RN with advanced training

16. Question What is the oldest model of nursing? • Modular nursing • Total patient care • Primary care • Case management

17. Answer Answer: Rationale:

18. Question What kind of care uses relatively unskilled workers who have been trained to complete certain tasks? • Modular nursing • Case management nursing • Functional nursing • Team nursing

19. Answer Answer: Rationale:

20. Common Features of Disease Management Programs • 1. Provide a comprehensive, integrated approach to the care and reimbursement of common, high-cost, chronic illnesses • 2. Focus on prevention as well as early disease detection and intervention to avoid costly acute episodes but provide comprehensive care and reimbursement • 3. Target population groups (population based) rather than individuals • 4. Employ a multidisciplinary health-care team, including specialists

21. Common Features of Disease Management Programs—(cont.) • 5. Use standardized clinical guidelines—clinical pathways reflecting best practice research to guide providers • 6. Use integrated data management systems to track patient progress across care settings and allow continuous and ongoing improvement of treatment algorithms • 7. Frequently employ professional nurses in the role of case manager or program coordinator

22. Selecting the Optimum Mode of Organizing Patient Care • The mode should be based on patient acuity and not economics alone • The knowledge and skill required for particular activities with specific populations should always be the true driver in determining appropriate care delivery models • Not every nurse desires a challenging job with the autonomy of personal decision making

23. Common Themes Found Among Emerging Care Delivery Models • 1. Elevating the role of nurses and transitioning from caregivers to “care integrators” • 2. Taking a team approach to interdisciplinary care • 3. Bridging the continuum of care outside of the primary care facility • 4. Defining the home as a setting of care • 5. Targeting high users of health care, especially older adults • 6. Sharpening focus on the patient, including an active engagement of the patient and her or his family in care planning and delivery, and a greater responsiveness to the patient’s wants and needs

24. Common Themes Found Among Emerging Care Delivery Models—(cont.) • 7. Leveraging technology • 8. Improving satisfaction, quality, and cost

25. Newer Health-Care Delivery Models and Nursing Roles • Nurse navigators • Clinical nurse-leaders • Nurses working in settings that embrace patient- and family-centered care

26. Core Concepts of Patient- and Family-Centered Care • Patient care is organized around the needs of patients • Patient and family perspectives are sought out and their choices are honored • Health-care providers communicate openly and honestly with patients and families to empower them • Patients, families, and health-care providers collaborate regarding facility design and the implementation of care • The voice of the patient and family are represented at both the organizational and policy levels as well as in the health system’s strategic planning

27. Question Which of the following is a core concept of patient-centered care? • Patient care is organized around the needs of the nursing staff • Patient perspectives are sought out and patient wishes respected • Health-care providers do not seek open communication with patients • The voice of the patient is not represented in planning

28. Answer Answer: Rationale:

29. Managing Care with Case Management • Case managers often manage care using critical pathways and multidisciplinary action plans (MAPs) to plan patient care • The care MAP is a combination of a critical pathway and a nursing care plan, which indicates times when nursing interventions should occur • All health-care providers follow the care MAP to facilitate expected outcomes • If a patient deviates from the normal plan, a variance is indicated

30. Disease Management • It is also known as population-based health care and continuous health improvement • It is a comprehensive, integrated approach to the care and reimbursement of high-cost, chronic illnesses • The goal is to address such illnesses or conditions with maximum efficiency across treatment settings regardless of typical reimbursement patterns • A continuum of chronic illness care is established that includes early detection and early intervention

31. Chronic Illnesses Often Managed with Disease Management Protocols Cancer Acute otitis media Diabetes Hyperlipidemia Asthma Hypertension COPD Hormone replacement therapy AIDS Stroke

32. Other Primary Features of DM Programs Include the Following The use of a multidisciplinary health-care team, including specialists in the area The selection of large population groups to reduce adverse selection The use of standardized clinical guidelines—clinical pathways reflecting best practice research to guide provider practice The use of integrated data management systems to track patient progress across care settings and allow continuous and ongoing improvement of treatment algorithms

33. Clinical Nurse-Leader • Experienced nurse • Graduate degree • Clinical leadership of all healthcare settings • Outcome-based practice • Quality improvement strategies • Clinical practice • Creates and manages microsystems • Responsive health-care needs of individuals and families

34. Characteristics of Effective Health-Care Delivery Systems • Elements of the various designs present in the system in use in any organization • Facilitate meeting the goals of the organization • Cost-effective • Satisfy the patient • Provide role satisfaction to nurses • Allow implementation of the nursing process • Provide for adequate communication among health-care providers

35. Work Redesign • Social interactions • Degree of autonomy • Abilities and skills • Employee evaluation • Communication patterns