Question

1. Explain the processes that were developed to optimize the continuum of care

2. Discuss the method used to develop a continuum of care in a community health- care setting

3. Identify and discuss the steps in the case management function

4.. Identify four core processes or elements in the care, treatment, and service of patients and state the common means by which healthcare organizations monitor and improve the quality of these elements of care

5. Describe how the National Patient Safety Goals interface with the performance improvement cycle during the patient care process

Answer 1

1 Continuum of care is the totality of health care services provided to a patient and his or her family in all settings ,from the least extensive to the most extensive.The four basic steps areplanning and management,care cordination,case based financing,integrated information systems.

2 Maintaining a patients continuum of care is important for a patient who is dependent n medical services.There are several methods to develop a ontinuum of care.

Determination of key roles-Identification ofthe specific provider who play a central role in the care team.

Flexible and understanding-The range of care have to be delivered over time.Therefore the careteam should maintain a level of flexibility.

Share info and insight -helps in easy acess to patients EHR across all health care providers

Start sooner vs later-IMonitor the patients progression and address potential care and collaboration issues earlier.

3 The case management process involes 9 phases such as

• Screening

it mainly focus on the reviewing of related information of a patients health condition.So that it will be easier to identify the need for health and human services.it also promotes early intervention.

• Assessing

it involves the collection of information about a patients situation as that of the screening process.during this stage the clients problem is identified and addressed as well as developm a comprehensive case management plan of care.

• Stratifying risk.

it involves the classification of client to three risk ctegories such as low,moderate and high.

• planning,

it establishe objectives,goals actions required to meet the clients needs.

• implementing

it deals with execution of the specific case management activities and interventions for achieving the goals.

• ,following up

it is centered on review,evaluation,monitoring,and reassessment of patients health condition.

• ,transitioning,

Based on the clients health condition and needed resources ,it focus on moving the client across the health and human services.

• communicating post transition

it involves communicating with a client support system for the purpose of checking on how things are going post transition from an episode of care.

• Evaluating

it calls for measuring the results of implementing the case management plan of care.

4 the four core processes are

• Assessing the patients needs-initial assessment determines the patients appropriateness for admission to the facility and the level of care to be rndered.
• physical,psychological,and social assessment.
• addictions,abuse ,pain.
• H&P within 24 rs of admission.
• Nursing assessment within 24 hours.
• Functional status.

Planning care,treatment and services-establishment of an interactive written careplan based on previous assements.

Providing care,treatment and services- it defines specific treatment and its timing and frequency

• core measures monitoring program
• patients status is continiously monitored for signs of stabilization,improvement or destabilization.
• patients and families should be involved.

Cordinating care tratment and services it is a defined process in the health care facility to recieve and hare patient info when the patient if referred primary care provider,community resources ,family or friends.

5 NPSG identify patient correctly.they help in improve staff communication,use medications safely,prevent infection,prevent bedsores.