Interprofessional Collaborative Practice and Care Coordination: Community and Home Health

Ch 12 : Community Health and Needs Assessment

Overview of Community Health

Community health focuses on the health status and needs of people living within a defined geographic area. It involves assessing and addressing both direct health needs and broader socioeconomic factors that influence well-being.

• Healthy People 2030: A set of leading health indicators guiding national health promotion and disease prevention efforts.

• Community Health Needs Assessment (CHNA): A systematic process for identifying and analyzing community health needs, such as employment, safety, housing, education, food environment, behavioral health, chronic diseases, and access to care.

• Direct Health Needs: Includes behavioral health, substance use, mental health, chronic diseases, dental services, and insurance coverage.

• Socioeconomic Needs: Encompasses employment, neighborhood safety, housing/homelessness, education, and food environment.

Example: Johns Hopkins Hospital conducts a CHNA to identify and prioritize health and socioeconomic needs in its service area.

Community-Based Health Care

Definition and Scope

Community-based health care is delivered to individuals within their local communities, emphasizing continuity of care, health promotion, and management of acute or chronic illnesses.

• Continuity of Care: Ensures smooth transitions between different care settings (e.g., hospital to home).

• Roles of Community-Based Nurses:

  • Provide interventions to promote health and manage illness

  • Promote self-care and patient independence

  • Act as patient advocates, coordinators, and educators

• Qualities of Community-Based Nurses: Knowledgeable, skilled, independent, and accountable.

Communication and Handoffs in Care

ISBARQ Method

The ISBARQ framework standardizes communication during patient handoffs to ensure safety and continuity.

• I – Introduction: Introduce yourself and your role.

• S – Situation: State the current situation or reason for handoff.

• B – Background: Provide relevant patient history and background.

• A – Assessment: Share your assessment of the patient’s condition.

• R – Recommendation: Suggest next steps or actions needed.

• Q – Question and Answer: Allow time for questions and clarification.

Example: During a transfer, the nurse discusses the patient’s background as part of the ISBARQ process.

Interprofessional Collaborative Practice

Team-Based Care

Effective health care increasingly relies on collaboration among professionals from different disciplines. Core competencies include communication, mutual respect, and shared decision-making.

• Components of Effective Teams: Clear roles, open communication, and shared goals.

• Care Coordination: The process of organizing patient care activities and sharing information among all participants concerned with a patient's care to achieve safer and more effective care.

Care Coordination and Transitions

Care Transition

Care transition refers to the movement of patients between health care practitioners and settings as their condition and care needs change.

• Aims of Care Coordination:

  • Link patients with community resources

  • Improve information exchange

  • Reduce fragmentation and duplication of services

• Care Coordination Ring: A conceptual model illustrating the interconnected roles and processes in care coordination. Additional info: The ring typically includes the patient, family, health care providers, and community resources.

Role of Nurse and Patient Navigators

• Nurse Navigator: A clinically trained nurse who identifies and removes barriers to treatment and serves as a central point of contact for patient care.

• Patient Navigator: May be a nurse, social worker, or layperson focusing on support aspects of care, such as helping patients access services and understand their care plans.

Vulnerable Populations

• People with disabilities or multiple chronic conditions

• Individuals with mental illnesses or substance use disorders

• Cultural, racial, and ethnic minorities

• People experiencing poverty, homelessness, or living in rural/urban underserved areas

• Undocumented immigrants

Admission, Transfer, and Discharge Processes

Admission to Ambulatory and Hospital Settings

• Ambulatory Care: Patients receive care without overnight stay; health history and pre-admission teaching are completed before arrival for procedures like same-day surgery.

• Hospital Admission: Involves preparing the room, admitting the patient, and completing medication reconciliation.

• Information Collected: Includes personal, demographic, and health-related data (e.g., name, DOB, physician, diagnosis, insurance, etc.).

Transfer Within and Between Settings

• Transfers may occur within a hospital or to extended care facilities, requiring careful communication and documentation.

Discharge Planning

Discharge planning is a systematic process that begins at admission and ensures patients have the support and resources needed after leaving a care setting.

• Essential Components:

  • Assess patient and family strengths and limitations

  • Assess the home environment

  • Implement and coordinate the care plan

  • Consider available resources

  • Evaluate effectiveness of the plan

• Criteria for Formal Discharge Plan and Referrals:

  • Lack of knowledge, social isolation, new chronic disease, major surgery, prolonged recovery, mental instability, complex care needs, financial difficulties, terminal illness

• Guidelines:

  • Assess needs, set goals, teach patient/family, provide referrals, evaluate outcomes

Leaving Against Medical Advice (AMA)

• Patients are legally free to leave but must sign a release form after being informed of risks.

• The signature must be witnessed, and the form becomes part of the medical record.

Telehealth and Home Health Care

Telehealth

Telehealth, or telemedicine, uses electronic communication technologies to provide health care remotely, increasing access and convenience.

• Services include wellness visits, prescriptions, dermatology, eye exams, nutrition counseling, mental health counseling, and some urgent care.

• Benefits: Reduced exposure to illness, shorter wait times, and improved access.

Home Health Care Services

• High-Technology Services: Advanced medical treatments provided at home (e.g., IV therapy, ventilator care).

• Skilled Professional/Paraprofessional Services: Nursing, physical therapy, occupational therapy, and home health aides.

• Custodial Services: Assistance with activities of daily living (ADLs).

• Hospice Services: End-of-life care focused on comfort and quality of life.

• Home Medical Services: Delivery and maintenance of medical equipment.

• Community Support Services: Meals, transportation, and social support.

Concepts of Home Health Care

• Involves patients and family caregivers in care delivery.

• Requires referrals and physician orders.

• Emphasizes safety, infection prevention, and legal considerations.

• Reimbursement may come from insurance, Medicare, Medicaid, or private pay.

Sample Table: Criteria for Formal Discharge Plan and Referrals

Criterion	Description
Lack of knowledge	Patient or family does not understand the treatment plan
Social isolation	Limited or no support system at home
New chronic disease	Recently diagnosed with a long-term condition
Major surgery	Undergoing significant surgical procedures
Prolonged recuperation	Extended recovery period anticipated
Emotional/mental instability	Patient has psychological or emotional challenges
Complex home care regimen	Requires multiple or complicated treatments at home
Financial difficulties	Limited ability to pay for care or resources
Terminal illness	End-of-life care needs