Continuity of care across settings [Level 3] What happens when a patient/client moves to a different setting ie home hospital hospice clinic etc How is communication handled so the patient/family needs are consistently met across settings?
WRITE a paper (at least 750 words) on a Innovative Nursing Care Delivery Model.
a)Baccalaureate-prepared nurses are expected to function as managers, educators, collaborators, advocates, and leaders within a variety of settings. For this paper, you will develop a model that is reflective of nurse managed care (see end of instructions for an example of a nurse-managed model).
Students in this course currently work or have worked in many different health care settings (acute, community, armed services). Choose ONE of the following areas of health care (Ignore nursing education/curriculi models):
Palliative and End of Life Care?
b)Content of paper:
Title of Paper (top of page 2, centered) Innovative Nursing Care Delivery: [Name of Your Model]
PAPER HEADING: [Level 1] Introduction Explain why you chose the setting. In the past, I?ve had students use settings in specialty units in hospitals; community housing and/or clinics; schools; health provider offices; armed services, rehabilitation, hospice, or ambulatory health care centers; client homes; nursing homes, short term stay housing; etc. What is your model?s goal(s) and/or purpose(s) and target population(s)? Choose a name for your model and include it in your paper title.
PAPER HEADING: [Level 2] Description of the [Name of Your Model] You are welcome to use your creativity in the model?develop your own or base it on an existing model. For ideas, start with the article found with the assignment or do literature searches on the internet. However, be sure that the model is nurse-led or nurse-managed. Registered nurses have authority to make decisions regarding nursing diagnoses, interventions, and referrals. Registered nurse practitioners have additional authority related to medical diagnoses and interventions (prescriptions). Be sure to include the themes crucial to meeting the challenges of the future: nurse- managed care, collaboration, continuity of care and technology in describing your model. Be aware of cost-effectiveness; you could develop the ?Cadillac? of models, but no one would consider implementing it because the cost would be too high.
Nurse led and nurse managed health care. [Level 3] How is your model nurse managed? Were nurses instrumental in the development and implementation of your model? Are nurses consulted and/or make decisions re: budget, personnel, and the communication, referral, and evaluation processes?
Partnerships and collaboration. [Level 3] What partnerships and collaborations exist for your model? Are they at the professional level (i.e., social workers, dietitians, community leaders) and/or the organizational level (home health care agencies, public health departments)?
Continuity of care across settings. [Level 3] What happens when a patient/client moves to a different setting, i.e., home, hospital, hospice, clinic, etc. How is communication handled so the patient/family needs are consistently met across settings?
Technology. [Level 3] What technology is used? Is it high-tech (i.e, patient monitoring & data processing systems) or low-tech (assessment tools, diagnostic tests) or a combination of both?
PAPER HEADING: [Level 2] Development/Implementation Team for the [Name of Your Model] Your team is important to carry out model?s goal(s). Depending on your model and setting, your team may include other registered nurses, nurse practitioners, community workers, nurse assistants, licensed practical nurses, dietitians, physical therapists, occupational therapists, dentists, social workers, community leaders,
psychologists, clergy, administrators, informatics technicians, physicians (if physicians are part of the team, they should function as consultants, not ?captain of the ship?). Discuss your team members and their functions in carrying out the model goal(s)/purposes(s). How would communication and referrals be handled? Again?think about the cost effectiveness?could ancillary staff (nurse assistants, trained community workers) be used just as effectively?
PAPER HEADING: [Level 2] Evaluation of [Name of Your Model]: Outcome Measurement After implementation of the model, what outcomes would you measure and how and when would you measure those outcomes? Be specific on how and when. Would you look at cost comparisons and/or savings? Patient satisfaction? Staff satisfaction? Fewer ER visits and/or re-hospitalizations? Increased knowledge of a disease or intervention?
c) An example of a nurse-managed model:
Below is an idea for a nurse-managed model. Your paper would be organized per the assignment instructions and more detailed regarding the health care delivery (nurse-led, collaboration/partnerships, continuity of care, and technology), and the functions of each of the team members, etc., but this is the start of an idea:
Let?s say you are a nurse working in community health and you are aware of three large migrant communities located in the rural areas around Homestead, Florida. The migrant workers who reside in these communities include their families?from infants to elderly. The communities are isolated and lack transportation and the ability to pay for and access local health care facilities.
You develop a model named Bus Stop for Health. You obtain funding (donor and/or grant) to refurbish a bus or utilize a refurbished bus already owned by a local health care organization. The bus will include an examination room (with assessment devices, such as BP cuffs, otoscopes, exam tables), supplies for health screenings (i.e., diabetes, cholesterol, pap smears, etc.), and two rooms for consultation. An informatics technician (IT) will establish a computerized (e-tablet) system to input, store, and access data in the field. Smart phones will be used for real time communication.
After consultation with and permission from the local community leaders in the migrant communities, the bus is scheduled to drive to and spend 1-2 days/week at each migrant community. The purpose of the bus is to provide primary health care (preventative care, such as immunizations and well child exams), monitor chronic diseases, such as hypertension and diabetes), diagnose and treat minor illnesses, and provide health- related education for this population. A referral system will be established for specialty care, such as obstetrics. Some folding chairs and a tarp will be carried in the bus so small covered outdoor or indoor health education sessions can be provided.
Regular team members on the bus will consist of a nurse practitioner, registered nurse, and receptionist/translator. Other team members will rotate in and out of the scheduled bus times on a regular basis. For example, you could include a social worker, dentist, and psychologist (describe their specific functions/purposes for this migrant population) as rotating team members. A consultant and referral relationship with a physician or physicians could be established for more complicated health care problems. A nurse midwife would also be included in the bus rotation for managing low risk pregnancies. Commonly prescribed medications can often be obtained through pharmacies at reduced costs or free from donors.
Evaluation? Some outcomes looked at could be increased immunization rates, increased knowledge related to common chronic diseases, child safety, etc. (by using pre & post tests), reduced visits to the local ERs for minor illnesses), earlier prenatal care, or other outcomes of interest.
d) Use the above headings in your paper. In-text citations and a reference list MUST be found in your paper. Fifteen (15) points will be deducted for incorrect citations and/or references. See the Nursing Student Writing Guidelines Checklist for APA formatting.
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