Community Health/case management nursing

Notes:

The population that we are focusing on are senior from 65 and up. Need support for transportation and ADL (acitivites of daily living)

Many of the seniors have depression, diabetes, hypertension, cardiac issues (stroke)

Lives alone but still wants to be independent.

Unable to maintain their home, for example, one patient have too many things and cannot move around the house, which becomes unsafe. Can’t even access the restroom since there are many boxes blocking entrance to the house.

Another patient unable to feed their pets, example, dog, there is poop all around the house

2 patients-failure to thrive after spouse passed away

Another patient experience their caregiver (whom is in prison) take money from their account

 

Foundation of Senior care in fallbrook was the site that I did my community/case management clinic. Check out their site for information for the paper.

 

https://foundationforseniorcare.org/

 

You will need to know the resources that is offer or who they team up for the paper like Adult Protective service, elder lawyer, etc

 

They live in Fallbrook, Ca

Most of them have medicare and medical (which only covers for for health insurance)

 

The assignment will consist of the following:

 

1. Select a population for which care was provided. Write a comprehensive, holistic assessment, choose a nursing diagnosis based on one of the issues from the assessment, and then follow it through the remaining 3 parts of the nursing process. Integrate Orem Self-care Theory into assessment and care of clients. See specific instructions at end of syllabus.
2. Based on the weekly discussion topics, respond to all of the bullet points listed that week.
3. QSEN Competencies- include two different competencies with each assignment. See description below and in rubric.
4. Journal on things learned, challenges faced and new experiences. See rubric.
5. Include at least two references, at least one recent, peer reviewed journal article is required. Articles can be no more than 5 years old.
6. As this is a formal, though short paper, use APA format including rules of grammar. See the grading rubric at the end of the syllabus.

 

7. QSEN Competencies: Throughout the Community Health Nursing and Nurse Case Management clinical rotation, students will be evaluated on their ability to demonstrate the knowledge, skills, and attitudes necessary to provide safe family centered care that is informed by the QSEN Competencies.  The competencies below will provide the framework for clinical assignments. The clinical faculty member will review the assignment content and provide feedback to further assist the student in meeting clinical objectives and to promote awareness of the QSEN competencies. These clinical objectives outline knowledge, skills, and attitudes (KSAs) that are specifically outlined in the “Quality and Safety Education for Nurses” (QSEN) Core Competencies.   For more information, students are encouraged to visit http://www.qsen.org/competencies.php

 

1. Quality Improvement:

Identify gaps between local and best practice.

Seek information about quality improvement projects in the care setting.

 

1. Patient Centered Care:

Initiate effective treatments and health promotion strategies in light of patient values, preferences, and expressed needs.

Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management.

 

1. Teamwork & Collaboration

Communicate care provided and needed at each transition in care.

Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care.

 

1. D. Evidence Based Practice:

Locate evidence reports related to clinical practice topics and guidelines.

Identify best practices for care of your clients.

 

1. Safety:

Demonstrate effective use of technology and standardized practices that support safety and quality.

Demonstrate effective use of strategies to reduce risk of harm to self or others.

 

1. Informatics: Navigate the electronic health record and demonstrate ability to identify community resources for clients.

 

Rubric for the assignment and more directions:

 

A total of 38 points is possible for each based on the following:

 

 

1. Population Nursing Care Plan portion – 22 points

 

How to do a population care plan: When the focus is on a population, include: comprehensive, holistic assessment of the population with demographic info, social history, needs assessment, problem identification, and location & nature of services provided.

 

Based on your assessment of your population, when developing your nursing care plan, you must include the following:

 

1. Complete and summarize assessment of your population. Include demographic data. (2 points)
2. Identify at least two health-related problems with HP 2020 objectives. (2 points)
3. Select one of the problems and expand on nature of problem using appropriate Orem Self-Care Theory and NANDA diagnosis. Must include epidemiologic, subjective, and objective data to support diagnosis. (2 points)
4. Create nursing plan of care with the following areas of interventions (10 points)
   1. Nursing care to include coordination of care/case management (excluding education and advocacy). (2 points)
   2. Teaching/education for all levels of prevention (primary, secondary, tertiary). (6 points)
   3. Advocacy plan for the health problem in this population (this is what you as a nurse in your community can do working with your community partners). (2 points)
5. In developing your plan of care, you will need to have expected outcomes with outcome criteria and timelines for health education, advocacy, and coordination of care. (6 points)
   1. Demonstrate delivery of health education with the identification of one education outcome with appropriate outcome criteria and timeline. (2 points)
   2. Demonstrate advocacy of your patient or population with one appropriate expected outcome with appropriate criteria and timeline. (2 points)
   3. Demonstrate coordination of care by identifying case management strategy/coordination of care (not including teaching or advocacy) with one expected outcome with appropriate criteria and timeline. (2 points)

 

 

2. Discussion –4 points

Address the bullet points from the syllabus for the week the assignment is due.

Provide references as appropriate.

 

3. QSEN –4 points

Identify Two QSEN competencies that you met this week and describe how they were applied. Every assignment requires inclusion of two of the competencies that had not been previously addressed so that four are covered by the end of the semester.  You will receive 2 points for describe and define QSEN competencies and 2 points for giving appropriate examples from clinical (4 points for each competency in each area).

 

4. Journal – 4 points

Write/communicate personal feelings and insights into the care that was provided, the experience, location, or what was learned.

 

5. Format – 4 points

Correct use of APA guidelines, spelling, and grammar.  Length is to be 4-6 pages not including title page or references Use of appropriate and sufficient references (minimum of 2, recent – within the last 5 years, peer-reviewed journal or expert sources such as CDC, NIH, AHA, & WHO).