Week 6: Discussion on Continuity of Care

Step 1: View the following video: Why care continuity means never discharging

patients:https://www.youtube.com/watch?v=mx08kmDxgmM (Links to an external site.)

Step 2: Review the Continuity and Coordination of Care by the World Health Organization: https://apps.who.int/iris/bitstream/handle/10665/274628/9789241514033-eng.pdf?ua=1 (Links to an external site.)

Step 3: Read the following article – How important is continuity of care. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083711/pdf/381.pdf (Links to an external site.)

Step 4: View the following video: Communicating with Doctors as a New Nurse or Nursing Student Tips:https://www.youtube.com/watch?v=Jr4gfgZzMjc (Links to an external site.)

Continuity of care is defined as the sound, timely, smooth, unfragmented and seamless transition of a client from one area within the same healthcare facility, from one level of care to a higher and more intense level of care or to a less intense level of care based on the client's status and level of acuity, from one healthcare facility to another healthcare facility and also any discharges to the home in the client's community.

Maintaining the continuity of care requires that the nurse, and other members of the healthcare team, identify current client needs and then move the client to the appropriate clinical area, to the appropriate level of care, and to the appropriate healthcare facility in a timely and effective manner.

The Nurse’s role in Continuity of Care:

• Coordinate care with the interprofessional team
• Act as a liaison and be a client advocate
• Complete admission, transfer, discharge, and post-discharge prescriptions
• Initiate, revise, and evaluate the plan of care
• Report the client’s status
• Coordinate discharge planning
• Facilitate referrals and use of community resources

Communication, collaboration and cooperation among and between appropriate healthcare team members and the client are essential components of the continuity of care.

Initial Discussion Assignment:

Part 1: Create a detailed scenario in which a patient with frequent re-admissions for Chronic Obstructive Pulmonary Disease (COPD) is successfully integrated into a care plan that exhibits continuity of care from admission to successful discharge to home with follow-up visits and monitoring. You are not allowed to simply agree or disagree in your responses to the initial postings. All responses must have evidence-based reasons why you agree or disagree and must be supported by research. At least one evidence-based article must be referenced.

Part 2: Your patient has transitioned home; however, during a follow-up visit you notice that the patient is having a mild exacerbation and you need to notify the patients doctor for possible admission. Create a detailed ISBAR report prior to calling the physician.