Organizing Patient Care
Paula Ponder MSN, RN, CEN
Fall 2010
Learning Objectives
• differentiate among various types of patient
care delivery systems
• discuss the relationship between managed
care and case management
• list the essential components of total patient
care, team nursing, primary nursing, and case
management
• discuss how work redesign may affect social
relationships on a unit
• explain what effect staff mix has on work
design and the patient care organization
Fall 2010
• What is our focus……
• Why are we here…….
• ….patients now more than ever
need reassurance that they are
indeed the focus of the healthcare
team
- Joan Shinkus Clark
Fall 2010
Traditional Modes of Care Delivery
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Total Patient Care
Functional Nursing
Team and Modular Nursing
Primary Nursing
Case Management
• Care delivery modalities (modes) affect autonomy and
job satisfaction.
• Direct pt care functions are actually caring for pt.
• Indirect pt care functions are like being able to self
schedule, charting
• All of these depend on what mode of care you are
using, and on how or when you get to use them
Fall 2010
Total Patient Care
• Total patient care - nurses assume total
responsibility for meeting all needs of assigned
patients during their time on duty
– For the entire shift nurse takes care of pt. Initially
occurred in ICU units
– Form of primary nursing
– Advantages – intensity of focus on the pt thru-out that
shift
– Disadvantages – lack of communication and lack of
continuity over time. Just meeting daily needs, not trying
to make a plan and get them out
Fall 2010
Functional Method
• Functional nursing - work assignment by functions or
tasks, such as passing medicine, doing dressing
changes, giving baths, or taking vital signs
• Assignment by function. Everybody has a task. Norm in
the US hospitals from late 1800’s til the end of WWII.
There was a shortage of nurses at the time, so we put
people in who can do things, like a team who went thru
and checked dressings, a team that took vital signs, etc.
• Advantage – no role confusion. You knew what you
were doing. This method is efficient and cheap.
• Disadvantage – client couldn’t identify who their
caretaker was, because there were so many caretakers.
Fall 2010
Team Nursing
• Team nursing - a team of RNs, licensed practical
nurses (LPNs), and aides under the supervision of
one nurse, called the team leader
– Group can be 10-20 pt’s to 4-5 nurses. Over each group
of teams is a charge nurse. Has evolved into modular
nursing (more of a spacial thing). Clients are grouped by
a floor plan, happens a lot in ED’s. We’re in pod A, which
has 10 beds, it’s intermediate care, and we’re in pod A
all day. RN assigns work on team members expertise.
Who’s good at what, what can this person do, and
where do you want to put them. You’re accountable for
delegating things to people who are trained to do them.
Fall 2010
Primary Nursing
• Primary nursing is an approach in which a nurse has
responsibility and accountability for the continuous
guidance of specific clients from hospital admission
through discharge
– She would be assigned a group of pt’s (kind of like a
nurse manager) and she’s responsible for them their
entire hospital stay. Ponder thinks it sounds very
challenging.
– Hallmark to this is that you have
autonomy/accountability 24 hours a day. You make
treatment decisions and what not
Fall 2010
Case Management
• Case management in acute care hospital nursing
has been defined as a system of client care delivery
that focuses on the achievement of client outcomes
within effective and appropriate time frames and
resources
– Also focus on containing health care costs first for the pt,
then for the facility.
– Practicing case manamgement can also be- I get this pt
and I check him and I consult all these specialists (like
neurologist and social workers) about his condition and
checking his discharge stuff and looking over everything.
Sometimes hospitals don’t have specific case managers,
but every nurse is expected to be their pt’s case
Fall 2010
manager…
CASE MANAGEMENT SERVICE AREAS
Category
Service Setting
Acute
Orthopedics, cardiovascular, critical care, high-risk perinatal, oncology,
emergency department
Subacute
Skilled nursing centers, rehabilitation units
Ambulatory
Physician's office, clinics
Long-term care
Nursing homes, group homes, assisted-living facilities
Insurance
companies
Health maintenance organizations (HMOs), preferred provider organizations
(PPOs), workers' compensation, Medicaid, Medicare
Community
Nurse-managed centers, home health agencies, urgent care centers, schools,
rural settings
Fall 2010
Disease Management
• Common high-cost, high-resource utilization
diseases
• Population-based health care
– Covered lives
• Continuous health improvement
• A population with a costly disease, people who are
on outpt dialysis. Focus is on the population. We
want to provide optimal, cost effective care. By
doing this we can actually do a lot of prevention
(hopefully). Going to diabetic clinic and teaching
them so we can hopefully prevent them from
reaching the need for outpt dialysis.
Differentiated Nursing Practice
• Education Model (Type 1)
– Based on type of education
– They’ve been trying to do this for a long time
• Competency Model (Type 2)
– Based on individual skill level
• Benner’s Novice to Expert (goes along with
competency model)
– Novice
– Advanced beginner
– Competent nurse
– Proficient nurse
– Expert
Fall
2010
Differentiated Nursing Practice Cont.
• To match the pt’s needs with nursing competence,
and have the most efficient use of nursing
resources.
• Education based thing really irritates Ponder. She
thinks RN’s who pass boards are RN’s who pass
boards.
• Competency she agrees with. Placing SICU nursing
in SICU, not taking a newborn nurse and putting
them in SICU. That’s not fair to the SICU pt.
• Match the pt’s needs with the abilities of the nurse
The Future
• Nursing shortages and health care reform have had
a strong impact on the creation of new and
evolving types of patient care delivery models.
– We’re seeing pt focus teams. By that she means the
teams have nurses, PT, OT, Dietary, any body else that
you can possibly thing of. Everyone gets an input, and
you have all the teams working together.
The challenges
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Fall 2010
Cost containment
Demand for quality outcomes
Information age
Patient population
Multigenerational workforce
The Optimum Mode of Care
• Carefully constructed
• Not based solely on economics
Fall 2010
Integrating Leadership Roles
• No one best mode
• Accomplishment of unit goals
• Seeking solutions not finding fault
– Working together
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Facilitates innovative thinking
Ensures adequate resources
Reduce resistance
Remember, change is inevitable
Fall 2010
Summary
• Nursing leaders and managers have the responsibility to
facilitate the design of care delivery models
• Nurses deliver and coordinate patient care
• The challenges for patient care in the future are massive
• The work environment of the nurse is dramatically different
from any other time
• Discover innovative ways to organize and deliver care
Fall 2010