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:red_flag:Care Navigation & Coordination L10 :red_flag: (What Patient…
:red_flag:
Care Navigation & Coordination
L10 :red_flag:
Care Coordinator :silhouette:
Play an important role for providing quality of care for patients who have acute, chronic, palliative or rehabilitative healthcare needs
Role (patient care)
responsible for assigned patient
Build rapport & trust with client
Conduct regular follow up
Monitor the patient condition
Educate the patient regarding his/ her condition
Assist in client with planning the services that he/ she choose
Conduct home assessment to ensure that safety is compliance
Understand what services are available for the patient
Assist patient navigator in care planning & coordination
Collaboration with multidisciplinary team & community providers
Acting as liaison person between patients, community, healthcare team & institutions
Challenges working in Care Coordination/Navigation :warning:
Cultural Barrier
Environment
Language Barrier
Patient Engagement
Support from colleagues
Independent working
Decision Making
Physical Demand
Emotional / Psychological demand
Care navigation and coordination services help patients, requiring different health services, agencies and professionals, through a confusing seascape of health, social and community care
Transition from restructured hospital --> Community :silhouettes:
Home based
Senior home care
Meals-on-wheel
Interim caregiver
Community case manager
Home nursing/ medical/ therapy
Centered-based
social day care
dementia day care
psychiatric day care
hospice day care
day rehabilitation
SPICE
Institution-based
: :
Community hospital (rehabilitation, sub-acute, palliative)
Nursing home (general, TCF, dementia, psychiatric)
Hospice
What Patient Navigator and Care Coordinator do at home visit :check:
Build Rapport with the patient first
Assessment
Educate patients
Medicine Reconciliation to avoid medication errors such as omissions, duplication or dosing error
Referrals e.g. Community support, health/rehab services
Reinforcement on End of Life Care Education (if applicable)
Patient & Family/Caregiver Education
Provide contact details
Provide contact details for support
:star: SBAR4 Care Framework :star:
Situation
Purpose patient see me and what is the diagnosis?
Is readmission preventable
Decisions to be made during this encounter
Background
Co-morbidities of patient and BPS issues that affects patient's health
Assessment
Clinical state of patient at current
Understanding of all issues stated in Background from team and patient's perspective
Recommendation
Best course of action for issues listed in Background
Ensure patient understand the reason behind the action plans
Resource
List the appropriate Health and social services for patient
Responsibility
How to convince patient to help himself
The roles and responsibility of service providers and different team members
Relationship
Coordination and work closely with team members and service providers
Establishing on-going therapeutic relationship with patient and caregiver
how does care navigation and coordination helps patients in their discharge home:question:
Care navigation explore financial assistance for the patient when they are discharged
They are in position in resolving caregiver disputes
Care navigation are trained as nurses and act as a clinical liaison between patients, family, staff and the healthcare system to coordinate patient’s treatment plans
A care coordinator job is often the single most important role involved in the care of any individual patient
Supervising interdisciplinary care by bringing together the different specialists whose help the patient may need, the coordinator is also responsible for monitoring and evaluating the care delivered .
Multi Disciplinary Team :fire:
Nurse
Doctor
MSW
Physiotherapist
Occupational therapist
Speech therapist
Common Post Discharge Issues at Home
Caregiver stress and capability
Non-compliant to medication, Medication errors
Poor awareness on own health condition
High risk of falling
Unsafe Environment
No advanced care plan
Did not check on supply and condition of medication e.g. empty syringes or throw expired medication
Deconditioning