cptr 12.docx - NUR 340 Chapter 12 Collaborative Practice...

NUR 340
Chapter 12 Collaborative Practice and Care Coordination Across Settings
 People enter health care services and are pts for all different reasons and have different needs,
in different settings, have different experiences; the nurse is often the one that helps in
transitions for the pt and family with consideration of many factors
Community-Based Nursing Care
 Health care provided to people who live within a defined geographic area; each community is
unique defined by the people, area, social interactions, and common ties within that
community; centers on individual and family health care needs
 Community Health/Public Health Nursing : population based, and focus is the health of the
whole community
o Not the Same!
 Community-Based Care emphasizes provision of comprehensive, coordinated, and continuous
services for pts with acute or chronic health problems
 Nurses help people where they themselves live, work, play, worship and go to school
 Nurses need to adapt to the pt’s environment and blend clinical skills with flexibility
 Nurses consider the continuity of the care pts require when moving from one level or setting of
care to another
Qualities of the Community-Based Nurse
 Enjoy practicing in an autonomous setting where they can use their expertise in an expanded
role, managing their time independently, get more satisfaction when pts welcome them to their
home and life, satisfaction in networking with community facilities, opportunities to be creative
in delivering care
 Knowledgeable and Skilled : effective communication and clinical skills, many facilities require a
minimum of 1 year clinical practice for employment, physical skills to identify +/- changes in pts’
health status, procedures required, home care requires knowledge of physical assessment, body
mechanics, nursing diagnoses, infection control, and legal regulations
 Independent in Making Decisions : and assume responsibility for decision making; combo of
sound theoretic foundation, proficiency in clinical skills, and problem-solving creatively
 Accountable : generally aren’t transferring accountability to the next nurse on shift, but relying
on family or other caregivers to continue the care; accountable to the pt, the family, the PCP;
who do I call if the pt’s MD/NP isn’t available? What should I do if a family member becomes
acutely ill? How do I learn to perform advanced procedures? How do I document the pt’s
decisions about tx? How do I work collaboratively and ensure that other providers know about
and document the care plan?
Roles of the Community-Based Nurse
 Patient Advocate : the protection and support of another’s rights; helping pts understand the
health care system, handling insurance problems, dealing with state and federal regulations
affect their care and environment, mobilizing services to improve their care and environment,
sometimes difficult to establish and maintain professional boundaries/sever ties
 Coordinator of Services : all other health care providers for the pt, the primary source of
communication and coordination of care with the PCP, effective communication and
coordination services, available community resources, providing comprehensive services,
understanding other providers’ roles
 Patient and Family Educator : about all aspects of care including disease processes and txs,
nutrition, medications, and tx and care of wounds; identifies learning needs, develop goals with