Community Based Care

Medical Surgical Critical Thinking

forCollaborative Care

Learning Objectives

• Explain the primary purpose of ambulatory care• Identify the features of nursing primary care• Discuss the growth of home care• Describe the role of the nurse in home care• Identify interventions for which Medicare pay in home care• State the purpose of OASIS in home care• Compare and contrast the common types of long term care

settings• Differentiate assisted-living from other types of long term

care• Describe the term transitional care

Community Based Care• Ambulatory Care• Is community settings like physician offices, hospitals, or freestanding

outpatient clinics, freestanding surgicenters, HMO (health maintenance organizations

• Purpose is health promotion, health protection (illness prevention), short-term treatment (i.e surgery), and follow-up for existing health problem

• Visits are Episodic or can be Periodic for chronic health condition• RN role

– Client education– Health screening– Comprehensive Assessment– Telephonic Case Management

Community Based Care

• Nursing Primary Care• Takes place in ambulatory care settings

sometimes called community centers• Sometimes affiliated with large university

schools of nursing• Primary health care providers are nurse

practitioners, midwives, clinical nurse specialist

Home Care• Preferred health care setting• Lowest cost setting• Promote, maintain, or restore health or maximize the level of

independence while minimizing effects of disability and illness• Continued shift• Increased acceptance as viable alternative• Baby boomers becoming more involved in decision making process• Aging has increased need for health care• Technology allow client to remain safely at home like apnea

monitors• Lower cost• Increased managed care that dictates lower cost

RN role in Home Care

• Draw on existing resources• Create resources thru use of family and

community support system• Adult health care (medical-surgical), pediatric

care, perinatal care, geriatric care, behavioral health care

Medicare & Home Care

• Beneficiary meets one or more of qualifying conditions:

• Confined to the home• Service are provided under a plan of care and

approved by physician• Client is under the care of a physician• Client needs skilled nursing care on an

intermittent basis or needs physical, speech, and or occupational services

Medicare & Home Care• Medicare pays for any or all of the following skilled nursing services: • Observation & assessment of client’s condition• Management and evaluation of a client care plan• Teaching and training activities• Administration of medications and IV fluids• Nasopharyngeal and tracheostomy suctioning• Urinary catheters• Wound care• Ostomy care• Rehabilitation nursing• Psychiatric evaluation, therapy and teaching

Outcomes and Home Care

• Regulations require Medicare-certified home care agencies to track and report client outcomes

• The Research-based tool for outcome tracking is called Outcome & Assessment Information Set (OAISIS) The report card for performance

• These outcome measures are the crux of Outcome Based Quality Improvement, a systematic approach that home care agencies can implement & follow for CQI

• Before OASIS was uniform data set to track their own outcomes and compare them to similar agencies

Types of Long Term Care Settings

• Residential Facilities• Assisted Living Facilities• Nursing Homes– Intermediate– Skilled nursing care– Chronic or Extended care

Transitional Care

• Transitional Care Units or Sub-acute Care Units are designed for client who are too ill to be discharged from the hospital to a traditional nursing home or the client home