Nurse Led Case Management Program For Older Adults With Co Morbidities

The majority population of long-term health facilities is comprised of geriatric patients with complex comorbidities. Studies show that one-third of these patients have cognitive impairments, and over one-half have physical limitations (Tjia, Bonner, Briesacher, McGee, Terrill & Miller, 2009). It is important to know geriatric patients have increased vulnerabilities. When patients are poor historians and family is unavailable, the nurse often becomes their only advocate during facility admissions. Adequate discharge planning is imperative for patient safety and successful transitions from hospitals to long-term care facilities. It is the equal responsibility of both care

Although the largest profession in the health care industry is nursing, a larger number of people are getting older and living longer. This means that more people will need nursing care, whether it’s in a hospital, a long-term care facility or at home. It is projected that long-term care facilities will need 66% more RNs by 2020 (Addressing the Nursing). The increase in life expectancy has amplified the complexity of health care because more people are living with chronic conditions. The American Nurses Association reported that “a large cross-sectional study of over 1,000,000 adults revealed that 82% had one or more chronic conditions” and we are seeing an increase of those age 65 and older living with multiple chronic conditions (Mion). Now, more than ever, there is a high demand for the best delivery of medical care.

To effectively manage the discharge of individuals and transfer of care between settings, the social service team at UPMC-MDU start early to anticipate problems and discuss barriers and reoccurring traumatic events, but most importantly, patients and multidisciplinary team, via daily meeting, are involved at all stages of the discharge planning and medical treatment process. Considering this process and significance to employ a person-in-environment approach, I have become more aware of the need for skillful care coordination to achieve the most successful clinical and

Patient-Centered Medical Homes (PCMH) are growing in popularity as the right thing to do improve patient care. PCMH are growing in popularity, as there is early evidence of their effectiveness (Egge, M. 2012). The PCMH concept has been widely promoted as a way to enhance primary care and deliver better care to patients with chronic conditions. This model of care has stimulated the attention of payers, Medicaid policy makers, physicians, and patient advocates, as it has the potential to address several of the limitations of the current healthcare system (Wang, J. et al 2014). Currently, primary care in the United States is focused on acute and episodic illness, it inadvertently limits comprehensive, coordinated, preventive and chronic care (Bleser, W. et al 2014). The PCMH address these limitations through organizing patient care, emphasizing team work, and coordinating data tracking (Bleser, W. et al 2014). A PCMH and HMO have some similarities but are markedly different.

Shared governance empowers nurses by recognizing that nurses, as front line staff, are in a position to have a unique understanding of the complexities of daily patient care. Utilization of unit-based councils made up of staff nurses to solve problems and evaluate procedures ensures that evidence-based best practices are implemented (Fray, 2011). Shared decision making in nursing units increases the use of best practices through process development, sharing of successes across multi-unit areas and in the development of new nurse leaders. Unit-based councils are often chaired by younger nursing staff and nursing leaders act more as facilitators allowing these young new nurses to be

The role of nurse practitioner is valuable when discussing collaborative care. There are so many levels of care, so many health entities, and so many insurer criteria involved that it is instrumental to have a role that can work towards help bring all aspects together. In addition to diagnosing, treating, and managing care, the role of the nurse practitioner is to manage simple and episodic acute health issues along with chronic disease (Sangster-Gormley, Martin-Misener, & Burge, 2013). It is important to note that although this is a function of this role, nurse practitioners also practice from a holistic point of view which allows them to help manage patient conditions or wellness in a more complete fashion. This includes helping patients have access to care beyond primary and secondary care settings. This encourages nurse practitioners to work alongside other health care and allied health professions, and families to create an individualized plan for every patient (van

The role expansion of nurses to meet efficiency targets has meant that nurse-led services in the healthcare setting are expanding as one means of coping with a growing, increasingly ageing population. For those nurses running nurse-led services the focus for that reason, needs to be on treatment that improves the quality of someone’s life and represents an

One of the aims of the Patient Protection and Affordable Care Act (ACA) of 2010 is improved integration and coordination of services for primary patient care. The patient-centered medical home (PCMH) is one of the approaches by which improvements can be established. The patient-centered medical home model is particularly well-suited for people who have chronic illness. The design of the patient-centered medical home model departs substantively from traditional reimbursement policies, in that, the ACA provides for incentives and resources to enable care coordinators to be directly recognized and compensated for their care coordination work. Care coordinators are most often registered nurses who through their work that aligns with ACA engage in quality improvement work, cost-effectiveness measures, and patient advocacy. To bring the ACA model to a human scale, the authors present a case study of a care coordinator at a patient-centered medical home in rural Maine. The table provided below provides a basic textual analysis of the study as it is published in the professional nursing journal.

The Self-Care Deficit Theory of Nursing impacts modern health as well as nursing more so than expected during its creation and evolution. The Institute of Medicine (IOM, 2001) demanded the need for health care to shift from acute care setting to management of disease. Consequently, today’s health care is in the midst of a paradigm shift, as it redirects its attention towards patient centered care, disease prevention and wellness promotion. The Affordable Care Act implemented regulations, enforced by financial reimbursement to ensure that hospitals have shorter lengths of stay, lower readmission rates and strategies to enhance health promotion, disease prevention and improved quality of life (Taylor, 2012). The government has placed incredible demands on the health care system as baby boomers are aging and chronic diseases are becoming more complex requiring increased use of technology and nursing support. In order to meet the legislative requirements, administrators and educators must transition to the structure and concepts provided by the Self-Care Deficit Nursing Theory, for it is in this theory, nurses are empowered to better care for the patients as they present with complex self-care needs requiring specialized assistance from highly advanced, educated nurses who prepare these patients to return home better equipped for self-care despite their chronic conditions.

The Gerontology Primary Care Nurse Practitioner competencies entail a combination of acute gerontology and primary care. In order to gain entry into this field, there is need to meet the requirements for an adult-gerontology care nurse practitioner. The competencies of this field are based on the APRN along with NP core competencies. Their scope of practice is based on patient healthcare needs. Their healthcare obligations tend to reflect the work of a national Expert Panel that entails a host of adults related to gerontology and acute care (Geetter, et al., 2013).

The focus of this paper is case management. Case management has evolved into a diverse profession which includes many disciplines and is exercised in many settings. Case management involves the process of coordinating multiple services on behalf of clients and has been practiced now for several decades. Many disciplines have engaged in case management and identify themselves as case managers. Case managers work with many populations and settings and play an important role in today’s society. The following analysis explores how case management developed, how it is defined, its components, and how it relates to other nursing care delivery models. All these aspects are reviewed with the purpose to show the importance of case management

The management of co-morbidities in America is an escalating dilemma for advance practice nurses (APNs). As an advance practice nurse (APN) continues to expand in her direct care role the depth and breadth of his/her advanced practice will focus on ongoing management and care of diverse populations that present to the APNs practice with hypertension and other co-morbidities which must be treated suitably with the best evidenced based approach and current guidelines aimed at promotion, maintenance and advancement of patient’s health, prevention or reduction in progression of maladies burden and cost. Hypertension and co-morbidities such as Type 2 diabetes mellitus (DM) and Hyperlipidemia are health problems frequently seen by practitioners with potentially ravaging, though preventable outcomes.

The healthcare industry has intensely advanced throughout the world, in turn changing the principles that incorporate the practice and culture of nursing practice. Altering the model of care to a patient-centered mode signifies an organizational culture shift and requires the participation of executives at the senior level (Cliff, 2012). To practice this care to provide the best care possible, it goes beyond the nurse to all healthcare professionals and senior leadership. The days of patients and nurses following a physician’s order without favor to care has now loaned themselves to more of an interdisciplinary approach to practice. Though, it is encouraged that the patient makes decisions for themselves, after receiving the proper education and information on their condition. Part of the patient-centered care is to be the patients’ advocate, by letting them know you are there for them when they are unable to speak and advocate for themselves and what is in their best interest. That goes in hand with educating them on “self-management of care, health literacy, patient, and family education through nurse-patient communication and interaction (Finkelman & Kenner, 2016, p. 271).”

The American Nurses Association is leading the way by implementing countless initiatives to bring attention to the nurses’ essential role in care coordination. It is up to the nurse to step up and draw attention to the integral part they play in improving patient satisfaction, patient care quality, and the effective and efficient use of health care resources (American Nurses Association, 2012).

Nursing care delivery is defined as the way task allocation, responsibility, and authority are organized to achieve patient care. Tiedeman and Lookinland (2004) suggested that systems of nursing care delivery are a reflection of social values, management ideology, and economic considerations. (Tiedeman&Lookinland, 2004) According to Fewer (2006), the quality of nursing care delivery systems affects continuity of care, the relationship between nurse and patient, morale, nurse job satisfaction and educational preparation.(Fewer, 2006) Nurses are essential human resources to provide medical services with professional knowledge and skills in the healthcare setting. However, the registered nurse turnover rate has increased in recent years resulting