Module One Voiceover - Key Points

Learning Objectives

• Understand the healthcare system and its complexity.
• Recognize the importance of integrated and coordinated care.
• Address challenges in care coordination, especially for vulnerable patients.

Healthcare System Overview

• Care must be integrated and coordinated across all health settings.
• Transitions of care are critical points where issues can arise.
• Vulnerable patients, especially those with chronic diseases, face greater risks during transitions.
• Issues include inadequate communication, unaddressed socioeconomic factors, and individual needs.

Role of Nurses

• Nurses play a vital role in addressing challenges in care coordination.
• Safety concerns arise during transitions like acute care to long-term care.
• Statistics show increased adverse events, readmissions, and higher costs.
• 76% of readmissions within 30 days are preventable.

Patient Protection and Affordable Care Act (ACA)

• Signed into law in 2010 to improve access, quality, safety, and lower costs.
• Transitional care programs aim to prevent avoidable readmissions, improve safety, and lower costs.

Transitional Care Programs

• Transitional Care Model: Team-based approach led by advanced practice registered nurses for older adults with chronic illnesses.
• Care Transitions Program: Nurses act as coaches to aid safe transitions.
• Project Red and Project Boost: Focus on improving discharge processes and reducing readmission rates.
• Patient-Centered Medical Home Guided Care Program: Coordinates care for patients with multiple comorbidities.
• Transforming Care at the Bedside Program: Focuses on quality and safety in patient care and nurse retention.

Patient Education

• Essential for safe transitions and to avoid readmissions.
• "Teach-back" method used to confirm patient understanding.
• Open-ended questions are encouraged to assess patient comprehension.

Nurse as Patient Care Coordinator

• Evolving role due to complexity in healthcare and chronic care management needs.

Interprofessional Collaboration

• Involves the whole healthcare team working together for optimal patient outcomes.
• Use of SBAR (Situation-Background-Assessment-Recommendation) for effective communication.

Delirium and RAS Scale

• Delirium: Altered mental state, can occur due to injury, infection, or hospitalization.
• RAS: Richmond Agitation Sedation Scale used to assess sedation in critically ill patients.

Hemodynamic Monitoring

• Used to evaluate patient response to treatments; involves monitoring cardiac output, stroke volume, preload, afterload, and contractility.
• Arterial catheter provides continuous blood pressure monitoring.

Oxygen Delivery and Consumption

• Oxygen consumption assessed through mixed venous gas measurements.
• Important in diagnosing conditions like cardiogenic shock.

Central and Pulmonary Artery Catheters

• Central Venous Monitoring: Measures preload, crucial for volume assessment.
• Pulmonary Artery Catheter: Measures heart pressures; useful in cardiogenic shock.

Prioritization and Case Management

• Prioritize patients based on complexity and discharge needs.
• Case management involves coordinating services for comprehensive care.

Final Tips

• Early identification and treatment of complex conditions are critical.
• Use hemodynamic monitoring to gauge treatment efficacy.
• Ensures efficient resource utilization and patient safety.