Nursing care delivery models • Nursing care delivery models, also called care delivery systems or patient care delivery models, detail the way task assignments, responsibility, and authority are structured to accomplish patient care.
Nursing care delivery models The nursing care delivery model describes • which health care worker is going to perform what tasks, • who is responsible, and • who has the authority to make decisions.
Nursing care delivery models • The basic premise of nursing care delivery models is that the number and type of caregivers are closely matched to patient care needs to provide quality care in the most cost-effective manner possible.
Nursing care delivery models • The four classic nursing care delivery models used during the past five decades are • (1) total patient care, • (2) functional nursing, • (3) team nursing, and • (4) primary nursing.
Total Patient Care • The oldest method of organizing patient care is total patient care, sometimes referred to as case nursing. In total patient care nurses are responsible for planning, organizing, and performing all care, including personal hygiene, medications, treatments, emotional support, and education required for their assigned group of patients during the assigned shift.
Total Patient Care • Registered Registered Registered • nurse 8-hour nurse8-hour nurse8-hour • shift shift shift • Patient care • The registered nurse • plans, organizes, • and performs all care. • The total patient care (case method) delivery model.
Functional Nursing • In the functional nursing method of patient care delivery, staff members are assigned to complete certain tasks for a group of patients rather than care for specific patients. For example, the RN performs all assessments and administers all intravenous medications; the LVN/LPN gives all oral medications; and the assistant performs hygiene tasks and takes vital signs. A charge nurse makes the assignments and coordinates the care.
Functional Nursing • Nurse Manager • LVN/LPNRN Nurse aide Nurse aide • PO Meds Assessments Vital signs Hygiene • Treatments Care plans Hygiene Stocking • Assignet Patient Group • The functional nursing care delivery model
Team Nursing • In team nursing the RN functions as a team leader and coordinates a small group (no more than four or five) of ancillary personnel to provide care to a small group of patients. "As coordinator of the team, the registered nurse is responsible for knowing the condition and needs of all the patients assigned to the team, and for planning the care of each patient" (Marquis and Huston, 2000).
Team Nursing • The team leader is responsible for encouraging a cooperative environment and maintaining clear communication between all team members. • The team leader's duties include planning care, assigning duties, directing and assisting team members, giving direct patient care, teaching, and coordinating patient activities.
Team Nursing • Nurse Manage • RN Team Leader RN Team Leader • RN RN • LVNs/LPNs LVNs/LPNs • Nursing assistants Nursing assistants • Assigned patient Assigned patient • group group • Team nursing model
Advantages of the Team Nursing Model • 1. High-quality, comprehensive care can be provided with a relatively high proportion of ancillary staff. • 2. Each member of the team is able to participate in decision making and problem solving. • 3. Each team member is able to contribute his or her own special expertise or skills in caring for the patient. (Marquis and Huston, 2000).
Disadvantages of the Team Nursing Model • 1. Continuity of care may suffer if the daily team assignments vary and the patient is confronted with many different caregivers. • 2. The team leader may not have the leadership skills required to effectively direct the team and create a "team spirit." • 3. Insufficient time for care planning and communication leads to unclear goals. Therefore responsibilities and care may become fragmented.
TEAM NURSING • Team nursing is an effective, efficient method of patient care delivery and has been used in most inpatient and outpatient health care settings. • The team leader must have strong clinical skills, good communication skills, delegation ability, decision-making ability, and the ability to create a cooperative working environment.
Modular Nursing • Modular nursing is a modification of team nursing and focuses on the patient's geographic location for staff assignments. • The patient unit is divided into modules or districts, and the same team of caregivers is assigned consistently to the same geographic location. • Each location, or module, has an RN assigned as the team leader, and the other team members may include LVNs/LPNs and UAP (Yoder Wise, 1999).
Modular Nursing • The concept of modular nursing calls for a smaller group of staff providing care for a smaller group of patients. • The goal is to increase the involvement of the RN in planning and coordinating care. • Communication is more efficient among a smaller group of team members (Marquis and Huston, 2000). • To maximize efficiency, each designated module should contain all the supplies needed by the staff to perform patient care.
Partnership Model • The partnership model, sometimes referred to as co-primary nursing, is a modification of primary nursing and was designed to make more efficient use of the RN. • In the partnership model the RN is partnered with an LVN/LPN or UAP, and the pair work together consistently to care for an assigned group of patients.
CASE MANAGEMENT • Evolution of Case Management • Case management is a model of care delivery in which an RN case manager coordinates the patient's care throughout the course of an illness. • The concept of case management was first introduced in the 1970s by insurance companies as a method to monitor and control expensive health insurance claims, usually created by a catastrophic accident or illness (More and Mandell, 1997).
CASE MANAGEMENT • Today, virtually every major health insurance company has a case management program to direct and manage the use of health care services for their clients. • Case management by payer organizations (e.g., health insurance companies, health maintenance organizations [HMOs]) is known as external case management.
CASE MANAGEMENT • The ANA has defined nursing case management as "a dynamic and systematic collaborative approach to providing and coordinating health care services to a defined population. It is a participative process to identify and facilitate options and services for meeting individuals' health needs, while decreasing fragmentation and duplication of care and enhancing quality, cost-effective clinical outcomes. The framework for nursing care management includes five components: assessment, planning, implementation, evaluation, and interaction" (ANCC, 2001, p. 1).
Components of Case Management • Assessment. • • Review the client's history and current status • • Perform comprehensive health assessment • • Identify available resources and support system (e.g., individual, family, financial, health insurance, community) • • Identify barriers to accessing necessary treatment (e.g., lack of health insurance coverage; no family support)
Components of Case Management • Assessment. • Identify health promotion and disease prevention opportunities • • Identify adherence patterns, educational needs, and ability to learn • • Determine potential for overuse or under use of resources • • Find, appraise, and use research findings as the basis for treatment decisions (evidence-based practice)
Components of Case Management • Planning. • Prioritize needs and set realistic, measurable goals and outcomes • Identify realistic treatment options • Coordinate various providers involved in the plan of care (e.g., physician, physical therapist, dietitian) • Determine appropriate levels of care and realistic treatment settings (e.g., home, long-term care, rehabilitation facility) • Identify and address gaps in care • Ensure continuity of care • Negotiate and manage financial aspects of care
Components of Case Management • Implementation • Ensure implementation of the care plan in a safe, timely and cost-effective manner • Coordinate services and referrals to providers or agencies • Ensure compliance with federal, state, and local regulations and standards • Use appropriate community resources • Document progress toward achieving goals and outcomes • Accept accountability for implementation of the care plan
Components of Case Management • Evaluation • • Measure clinical goals, functional improvement, satisfaction with services and cost-benefit of treatment plan • • Is/was the plan of care realistic, collaborative, and mutually beneficial to all involved? • • Are/were the established time frames realistic? • • Are/were the best possible and most cost-effective treatments used? • • Are/were individual educational opportunities maximized?
Components of Case Management • Interaction • • Interact on a daily basis with diverse groups of people: client, family members, and significant others; health care team members; payer representatives; representatives from other health care agencies and community organizations • • Motivate diverse groups to cooperate, collaborate, and work in the best interest of the client • • Use good communication, negotiation, facilitation, and documentation skills.
CASE MANAGEMENT • Nursing case management in a health care facility is a supplemental form of nursing care delivery and does not take the place of the nursing care delivery model in place to provide direct patient care. • Case management is not needed for every patient in a health care facility and generally is reserved for the chronically ill, seriously ill or injured, and long-term, high-cost cases.