Patient Case Summary

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 Board office received a letter from Mary Fahey, MPHP via fax on 05/04/2015, advising that Dr. John Medley, M.D. a current “ILOD” status had informed her that he had relapsed over the weekend of April 25-26, 2015.

According to 2010 patient protection and the Affordable Care Act, it was obvious that it needed all the possible help from all health professional, especially nurses for it to function and achieve all its aims such as affordable coverage and quality care, making all Americans to have health care that would improve the quality of life and inexpensive. There is no doubt if registered nurses do not have a strong position as partners in Affordable health care to make it a success. Three colleagues were interviewed regarding their knowledge concerning innovative health care conveyance including the current nurse’s responsibility in the health center environments, communities, health centers, as well as medical homes. Their questions were also expanded to their knowledge of Accountable Care organizations, the way they are organized, and the nurse’s opportunities in this program. What they know about medical homes and how they are organized, including nurse’s opportunities and their views on Nurse-managed Health Clinics (NMHCs and the nurse’s benefits).

On 10/01/2017 at 0014 hours, FTO Roman #2373 and I responded to 1346 Vermont St. regarding fight between a female and an individual she had a restraining order against. Dispatch advised that the suspect was a Latin male adult, approximately 28 yrs, 5’10, wearing a black jacket and black pants. Officer Roman and I were in full police uniform and driving a marked patrol vehicle when we responded. Upon arrival, Officer Roman activated his (BWC1) body worn camera and the footage was later uploaded to evidence.com.

Advanced practice nursing is an evolving field that is integral to the healthcare delivery system. The role of a nurse practitioner is to provide patient and family-centered care by practicing health promotion, disease prevention, and health education. With a shortage of primary care physicians nationally in the United States, there is a high demand for certified nurse practitioners to help meet the needs of patients across all age populations. According to the Consensus model, Advanced Practice Registered Nurses (APRNs) “are prepared educationally to begin practicing with responsibility and accountability to diagnose, treat and manage health problems including pharmacological or diagnostic interventions” (Stewart & Denisco, 2015). With a

Patient care has come a long way. Gone are the days of a “one size fits all” patient care plan and doctors who call all the shots. Today’s patient care is complex and heavily includes the most important person, the patient. Not only does the patient have a say in his/her plan of care, but interdisciplinary teams of healthcare professionals weigh in on the direction of care through empowered communication. As this system of care develops, all members of the team expand their knowledge, experiences, and professional development.

Gadsden is located in the northeastern corner of Alabama and is the county seat of Etowah County. It is 60 miles

As the delivery of care becomes more complex, the need to coordinate care among physicians, nurses, pharmacists, social workers, and others becomes ever more important. In the face of increasingly complex health issues, several institutions have proposed inter-professional education (IPE) as a way to improve teamwork among health professionals and move health systems from fragmentation to collaboration, with the goal of improving health outcomes (Schmitt, Blue, Aschenbrener & Viggiano, 2011). This key competency also has been included in the accreditation standards for pharmacy, medicine, nursing, and dentistry. Additionally, core competencies for Interprofessional Collaborative Practice were developed to provide tools to prepare future health professions for interprofessional, team-based, and patient-centered care (American Association of Colleges of Nursing [AACN] 2012). These collaborative competencies connects to the five core competencies identified by the Institute of Medicine and are instrumental in working effectively with other health professions, patients, and families (Bethea, Holland & Reddick, 2014).

Recently, my primary care clinic implemented a strategic initiative to increase patient accessibility to health care provider appointments. The managers within my clinic restructured our clinicians and nurses into health care teams called Patient-Centered Medical Homes (PCMH). PCMH involves realigning staff into teams around the primary care managers (PCMs) who have a support team helping them provide comprehensive, coordinated healthcare for patients (Army PCMH implementation manual, 2013). The PCMs are the physicians, nurse practitioners (NPs), and physician assistants (PAs) within our clinic. Each team has one PCM and three support staff (RN, LPN, CNA or medic) helping them provide care to their empanelment of patients (Army

To my fellow nurses. You are welcome to our professional nurse evolution summit. The United health care system is changing with the nursing profession. Health care cost has doubled, if not tripled in the recent years. The American population is ageing and diseases are becoming more complex. The Patient Protection and Affordable Care Act (PPACA) is one thing that will lead to change worldwide. With signing the PPACA into law, approximately 30 million Americans will benefit from affordable and accessible health care. (Institute of Medicine, {IOM}, 2011). My, discussion will focus on Accountable Care Organizations (ACO’s), Medical Homes, Nurse-managed health care clinics, and Continuum of care.

Lights of Zion will hire an experienced case manager/“reentry counselor,” to assist reentry experience from prison to sustained employment. The case management begins with a comprehensive individual assessment. From this assessment, a service plan is created that manages every aspect of the participant’s reentry program. The case manager monitors the plan, ensuring that all goals and objectives are being reached. Case manager Service will also participate in client recruitment, services, mentorship and job training and placement.

Patient-Centered Medical Home is a new model of care that highlights the importance of team approach when delivering care to the patients. It is a model that reorganizes the primary care practice across the United States. This model of care is proposing the idea of having a physician, nurse practitioners, physician assistants, nurses and other healthcare

Patient discharged 6/2/17 from the med team. Patient was noted to be noncompliant, refusing treatment, and post hospital care. Had been non-compliant with home care as well. Presented to the Emergency Department (6/7/17) with leg pain and weakness. There was a Medical Team evaluation with recommendation to discharge home. The patient apparently refused to go home. The Case was discussed with Dr. Ha. A second Med Team evaluation was completed with the same recommendation. Addition calls to Dr. Ha were placed. I was called around 11:30 PM (6/7/17) by Dr. Ha. She felt the main issue was the patient’s refusal to leave the Emergency Department.

Clinician facilitated a family therapeutic session between UC and his Father who is sponsoring UC. Clinician reviewed the Safety Plan and sponsor agreed to utilize the resources provided should the UC need such care. Sponsor indicates he was aware UC would travel to the USA and agreed to provide support and sponsor him. Sponsor indicated he wanted the UC to come live with him so that the UC can have a better education and economic opportunities. Sponsor states he and UC have been separated for many years, however, he has maintained ongoing contact with UC during this years. Sponsor expressed understanding of the responsibility of UC’s overall care and feels he can provide proper care for the UC. Sponsor indicates he will follow conditions

atisfaction (ANA, 2012). According to the ANA (2012), “Coordination of care is not a new concept to registered nurses. They understand that they are an essential component of the care coordination process to improve patients’ care outcomes, facilitate effective inter-professional collaboration, and decrease costs across patient populations and health care settings” (p. 1). As part of the Nurse of the Future Competencies, this ensures a successful outcome during the transition period from hospital to home (Massachusettes Department of Higher Education, 2010) because communication, professionalism, patient-centered care, and evidence-based practice are vital for the intervention to be successful. Part of the communication component is for nurses to educate patients thoroughly by assessing their health literacy capabilities upon discharge from the hospital. They should start