BackCommunity Health and Care Coordination in Personal Health
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Terms in this set (28)
Community health focuses on the health status and needs of people living within a defined geographic area, addressing both direct health needs and broader socioeconomic factors.
Healthy People 2030 provides a set of leading health indicators guiding national health promotion and disease prevention efforts.
A CHNA is a systematic process for identifying and analyzing community health needs, including employment, safety, housing, education, food environment, behavioral health, chronic diseases, and access to care.
Direct health needs include behavioral health, substance use, mental health, chronic diseases, dental services, and insurance coverage.
Socioeconomic needs include employment, neighborhood safety, housing/homelessness, education, and food environment.
Community-based health care is delivered within local communities, emphasizing continuity of care, health promotion, and management of acute or chronic illnesses.
Continuity of care ensures smooth transitions between different care settings, such as from hospital to home.
Community-based nurses provide health promotion, manage illness, promote self-care, act as patient advocates, coordinators, and educators.
They must be knowledgeable, skilled, independent, and accountable.
ISBARQ standardizes communication during patient handoffs to ensure safety and continuity of care.
I: Introduction; S: Situation; B: Background; A: Assessment; R: Recommendation; Q: Question and Answer.
It is team-based care involving professionals from different disciplines working together with communication, mutual respect, and shared decision-making.
Clear roles, open communication, and shared goals.
Care coordination organizes patient care activities and shares information among all participants to achieve safer and more effective care.
Care transition is the movement of patients between health care practitioners and settings as their condition and care needs change.
Link patients with community resources, improve information exchange, and reduce fragmentation and duplication of services.
A nurse navigator is a clinically trained nurse who identifies and removes barriers to treatment and serves as a central contact for patient care.
A patient navigator may be a nurse, social worker, or layperson who helps patients access services and understand their care plans.
People with disabilities, mental illnesses, substance use disorders, minorities, those in poverty, homeless, rural/urban underserved, and undocumented immigrants.
Preparing the room, admitting the patient, and completing medication reconciliation along with collecting personal and health-related data.
A systematic process starting at admission to ensure patients have support and resources after leaving a care setting.
Assess patient/family strengths, home environment, implement care plan, consider resources, and evaluate plan effectiveness.
When there is lack of knowledge, social isolation, new chronic disease, major surgery, prolonged recovery, mental instability, complex care, financial difficulties, or terminal illness.
Sign a release form after being informed of risks; the signature must be witnessed and recorded in the medical record.
Telehealth uses electronic communication technologies to provide remote health care, increasing access and convenience.
Wellness visits, prescriptions, dermatology, eye exams, nutrition counseling, mental health counseling, and some urgent care.
High-technology services, skilled professional services, custodial services, hospice, home medical equipment, and community support services.
Involves patients and family caregivers, requires referrals and physician orders, emphasizes safety and infection prevention, and involves reimbursement from various sources.