Presentation by: Mae Michelle F. Aguilar R.N.NRSG125A-1ORGANIZINGPATIENT CARE
Learning Objectives1. Get reacquainted with the Traditional Modelsof Organizing Patient Care their briefbackground as well as its advantages anddisadvantages.2. List the essential components of casemanagement and disease management.3. Know the different Leadership and ManagerialFunctions in Organizing Patient Care.
• FIRST and MIDDLE-LEVEL MANAGERS–influences the organizing phase of themanagement process at the unit ordepartment level.
• UNIT LEADER-MANAGER – determines howbest to plan work activities so thatorganizational goals are met effectively andefficiently.
• TOP LEVEL MANAGER – influence on thephilosophy and resources necessary for anyselected care delivery system to be effective.
Leadership Roles and Management FunctionsAssociated with Organizing Patient Care
LEADERSHIP ROLES1. Periodically evaluates the effectiveness of theorganizational structure for the delivery ofpatient care.2. Determines if adequate resources andsupport exist before making any changes inthe organization of patient care.
3. Examines the human element in workredesign and supports personnel duringadjustment to change.4. Inspires the work group toward a team effort.
5. Inspires subordinates to achieve higher levelsof education, clinical expertise, competency,and experience in differentiated practice.6. Ensures that chosen nursing care deliverymodels advance the practice of professionalnursing.
1. Examines the unit philosophy to ensure thatit supports any change in the patient caredelivery system.2. Selects a patient care delivery system that ismost appropriate to the needs of thepatients being served.MANAGEMENT FUNCTIONS
3.Uses scientific research and current literatureto analyze proposed changes in nursing caredelivery models.4. Uses a patient care delivery system thatmaximizes human and physical resources aswell as time.
5. Ensures that nonprofessional staff areappropriately trained and supervised in theprovision of care.6. Organizes work activities to attainorganizational goals.
7. Groups activities in a manner that facilitatescommunication and coordination within andbetween departments.8. Organizes work so that it is as cost-effectiveas possible.
9. Make changes in work design to facilitatemeeting organizational goals.8. Clearly delineates criteria to be used fordifferentiated practice roles.
TOTAL PATIENT CARE/CASE METHOD NURSING• Nurses assume total responsibility during theirtime on duty for meeting all the needs ofassigned patients.• Sometimes referred to asCase Method of Assignment.
• 19th Century – total patient care was provided in thehomes.
• Great Depression of the 1930’s– people can no longer affordhome care and began usinghospitals. Nurses and studentsalso became caregivers inhospitals and in public healthagencies.• 1930’s and 1940’s – hospitalsgrew and provided total carecontinued as the primarymeans of organizing patientcare.
• Provides nurses with high autonomy andresponsibility.• Assigning patients is simple and direct.• Lines of responsibility and accountability areclear.• Patient theoretically receives holistic andunfragmented care during the nurse’s time onduty.
• The patient may receive three differentapproaches to care, often resulting inconfusion for the patients.• Requires highly skilled personnel and thusmay cost more than some other forms ofpatient care.• May result to unsafe care when Nurses have aheavy patient load.
FUNCTIONAL METHOD• Personnel were assigned to complete certaintasks rather than care for specific patients.
• “Care trough others” - Nurses becamemanagers of care rather than direct careproviders.• UAP – Unlicensed Assistive Personnel
• Evolved as a result of World War II and the HillBurton Act.• Continued due to the “Baby Boom” after the War.
• Economical means of providing care.• Task are completed quickly with littleconfusion regarding responsibilities.• Allows care to be provided with minimalnumber of nurses.• Functions well in areas such as the operatingroom.
• May lead to fragmented care and thepossibility of overlooking patient priorityneeds.• May result to low job satisfaction.• May not be too cost effective because of theneed for many coordinators.
TEAM and MODULAR NURSING• Ancillary personnel collaborate in providingcare to a group of patients under the directionof a professional nurse.
• Developed in the 1950’sto decrease problemsassociated withfunctional organizationof patient care.
• Nurse acts as a Team Leader responsible forknowing the condition and needs of all thepatients assigned to the team and for planningindividual care.• Duties may include: assisting team members,giving direct personal care to patients,teaching and coordinating patient activities.
• A team should consist of not more than 5people.• Most team nursing was never practiced in itspurest form but was in combination of teamand functional structure.
MODULAR NURSINGMODULAR NURSING – a mini-team (2-3members approach)• Members are sometimes called “care pairs”.• A small team requires less communication,allowing members better use of their time fordirect patient care activities.
• Allows members to contribute their ownspecial expertise or skill.• Comprehensive care can be provided forpatient despite a relatively high proportion ofancillary staff.
• Disadvantages are associated with improperimplementation rather than with thephilosophy itself.e.g. insufficient time for team care planningand communication can lead to blurred linesof responsibility, errors and fragmentedpatient care.
PRIMARY NURSING• Primary Nurse assumes 24-hour responsibilityfor planning the care of one or more patientsfrom admission or the start of treatment todischarge or the treatment’s end.
• A.K.A Relationship-based Nursing.• Provides total direct care for patients.• Requires a nursing staff made up of onlyNurses.
• Developed in the 1970’sand uses someconcepts of totalpatient care and bringsnurses back to thebedside to provideclinical care.
• Associate Nurses – follows the care planestablished by the primary nurse when theprimary nurse is not on duty.• This structure lends itself well to home healthnursing, hospice nursing and other health caredelivery enterprises.
• Clear interdisciplinary group communicationand consistent, direct patient care byrelatively few nursing staffs allows for holistic,high-quality patient care.• High job satisfaction.
• Disadvantages in this method lie in improperimplementation.• Many nurses may be uncomfortable in thisrole due to lack of experience and skillsnecessary for the role.
• Introduced in the 1970’s by insurancecompanies as a method to monitor and controlexpensive health insurance claims.• Today virtually every major health insurancecompany has a case management program todirect and manage the use of health careservices for their clients.• Known as external case management.
• Mid 1980’s hospitals had recognized the needfor a case management model to managetreatment plans and length of stay ofhospitalized patients.• This was called internal case management orcase management “within the walls” of thehealth care facility.
What is…• A collaborative process that assesses, plans,implements, coordinates, monitors, andevaluates options and services to meet anindividual’s health needs throughcommunication and available resources topromote quality, cost-effective outcomes(CMSA, 2006)
• Focus is on individual patients, not populationsof patient.• Case managers handle each case individually,identifying the most cost-effective providers,treatments and care setting.
• Case Management Nurses can choose tospecialize in treating people with diseases likeHIV/AIDS or cancer, or you can work withpatients of certain age groups like geriatrics orpediatrics.
• ACUTE-CARE CASE MANAGEMENT– integratesutilization management and dischargeplanning functions and may be unit based,assigned by patient, disease based, or primarynurse case managed.
• Additional work efficiency due to geographicproximity, but more importantly, the benefitof establishing solid working relationshipswith the nursing and ancillary staff working onthe unit.• In general a case manager can handle a loadof 25 patients (Smith 2003)
• Use Critical Pathways and Multidisciplinary actionplans (MAPs) to plan patient care.• Care MAP – combination of Critical Pathway andNursing Care Plans.– This indicates the time when nursing interventionsshould occur and this must be followed by health careproviders.– Variance – anything that occurs to alter the patient’sprogress through the normal critical path.
• Cycle Time Reduction – involves reviewing theexisting process that provides a product orservice; determining wasted time or effort;and developing an improved, streamlined wayto achieve the same results more efficiently.(Furlow 2003)
BECOME A…CASE MANAGEMENT NURSEGET YOUR…Case Management nurse certification from the American Nurses Credentialing CenterPASS YOUR…National Council Licensure Examination(NCLEX-RN)GET YOUR..Associate Science of Nursing (ASN) Bachelors of Science in Nursing (BSN)
• Effective case managers should have 3-5 yearsof direct care experience, preferably withinthe specialty area in which they case manage.(Smith 2003)• Role should be reserved for the advancepractice nurse or registered nurse withadvance training (Huston 2002)
Qualities of a Case Manager• Extremely Bright• Well-developed interpersonal skills• Able to multitask• Strong foundation in utilization review• Understands payer-patient specifics andhospital reimbursement mechanisms.
DISEASE MANAGEMENT• One role increasing assumed by CaseManagers is coordinating diseasemanagement programs.
• DISEASE MANAGEMENT (DM) – alsoknown as population-based health care andcontinuous health care improvement, is acomprehensive, integrated approach to thehealth care reimbursement of high-cost,chronic illnesses.
• Includes early detection and early interventionas well as comprehensive tracking of patientoutcomes.• The difference of DM in Case Management isthat the focus is on “covered lives” orpopulations of patients, rather than on theindividual patient.
• GOAL: Serve the optimal number of coveredlives required to reach operational andeconomic efficiency.
• National Committee for Quality Assurance(NCQA) – began an accreditation process inJanuary 2002 for organizations that offercomprehensive DM programs.
Common Features1. Focus is on prevention as well as earlydisease detection and intervention.2. Population-based.3. Employs multi-disciplinary health care team,including specialists4. Use standardized clinical guidelines – clinicalpathways reflecting best practice research toguide providers.
5. Use integrated data management systems.6. Frequently employs professional nurses in therole of case manager or program coordinator.
DIFFERENTIATED NURSING PRACTICE“Expecting similar performance from nurses withvarying educational preparation can lead to roleconfusion, stress and burnout as nurses struggleto develop role competencies for which they havenot been prepared.” (Fox 2003)
• Refers to an attempt to separate nursingpractice roles based on education orexperience or a combination of both.
2 BASIC DIFFERENCIATED PRACTICE MODELS1. Education Model• Differentiation is based on type of educational preparation(AND, BSN, MSN)• Components: Provision of Care, Communication andmanagement.2. Competency Model• Based on individual nurse skill level, expertise and experience.• Benner’s five levels of practice (1984) and 8 ANA standards ofnursing. Also suggests the 21 Pew Health ProfessionalCommission Competencies.
Rationale• To match patient needs with nursingcompetencies.• Facilitate the effective and efficient use ofnursing resources.• Provide equitable compensation based oneducation, productivity and expertise.• Increase nurse satisfaction.• Build loyalty and increase the prestige of thenursing profession.
The Future for Patient Care andDelivery Models• Nurse as clinical expert leading othermembers of a team of partners.
• Creation of a new nursing role (the clinical-nurse leader) that is more responsive to therealities of the modern health care system.(Tornabeni, Stanhope, and Wiggins 2006)
• A cooperative model of care delivery throughlay care partners. They are taught to recognizesystems, identify problems and take action.
5 Components of Determining the Model ofNursing Care Delivery (Reno et. Al 2005)A. Conversion of manual systems intoautomated ones.B. Differentiated levels of nursing practice.C. Increased knowledge base of nursingpractitioners.D. Development of flexibility and nimbleness.E. Attraction of nursing candidates from a morediverse pool of professionals.
When Evaluating theCurrent System andConsidering aChange…
• Is it in line with the organizational philosophy?Does it facilitate or hinder organizationalgoals?• Is it organized in a cost-effective manner?
• Will it satisfy the patient and their families?• Will it provide some degree of fulfillment androle satisfaction to nursing personnel?• Does it allow implementation of the nursingprocess?
• Does it promote and support the profession ofnursing as both independent andinterdependent?• Does it facilitate adequate communicationamong all members of the health care team?
• How will it change the patient care deliverysystem, alter individual and group decisionmaking? Will autonomy increase or decrease?• How will social and interpersonal relationshipchange?• Will the employees view their unit of workdifferently?
• Will the change require a wider or morerestricted range of skills and abilities on thepart of the caregiver?• Will it change how employees receivefeedback?• Will communication patterns change?