Continuity of Care & Referrals (Nursing)

00:01 Hi, I'm Jessica Spellman.

00:02 We are going to be reviewing Continuity of Care.

00:07 After taking this course, you will be able to understand the concept of continuity of care, identify the nursing role in managing the continuity of care, utilize report format to promote continuity of care.

00:22 So continuity of care is an ongoing process.

00:26 It's interdisciplinary.

00:27 It involves the client and all health care providers for that client, and it is patient and family-centered . The goal is to have everyone involved understand the plan of care.

00:40 Continuity of care leads to safe, high-quality, cost-effective, patient-satisfied care. The nurse serves as a client advocate for required services, a liaison to other health care providers, organizer and provider of care.

01:01 Educator of patient and family regarding aspects of care.

01:06 Evaluator of care plan and outcomes as well as a facilitator of services including referrals for inpatient departments as well as community resources.

01:18 Continuity of care requires communication.

01:22 Information about patients are relayed in report.

01:26 There are a few types of report.

01:28 There's nurse to nurse report, nurse to physician report and facility to facility or unit to unit report.

01:37 In nurse to nurse report, ISBAR is the communication tool commonly used.

01:43 ISBAR stands for introduction, situation, background, assessment and recommendation.

01:52 Under introduction, you're going to want to introduce yourself and then introduce the patient to the oncoming nurse. That includes name, age, gender.

02:02 Then we move on to situation where we explain the chief complaint, reason for the visit or admission and the diagnosis. The background includes the past medical and surgical history, completed test results and what has happened, everything up until the time you're giving report.

02:21 You want to review the assessment with them.

02:24 A concise head-to-toe assessment labs, pertinent objective or subjective data. And recommendations, pertinent ongoing issues that aren't yet resolved, and an upcoming plan of care or things that the oncoming nurse may need to resolve during her shift.

02:43 When you call a physician to get orders on a specific situation, you want to also include the ISBAR format when you call them.

02:53 So you start with an introduction, you want to state your name, your designation, what unit you're on, you want to state the patient's name, age, sex, and an admitting doctor if you're not speaking to that physician.

03:09 You want to explain the situation and basically start with why you are calling.

03:15 So you want to say, I am calling about and then state the reason for the call.

03:19 You don't want to explain what happened to trigger the conversation with this physician and articulate your concern. You want to be able to provide them background, the reason for the patient's admission, history of the current problem, past medical history, state any relevant medical, surgical, social background that that may be part of the concern, and a brief synopsis of the treatment to date.

03:47 You want to include assessment data for the physician.

03:50 You want to state the patient's current vital signs, observations, outline what is recorded on the chart. You want to explain what you think the problem is, or what could possibly be going on, and then state what you have done for the patient so far.

04:07 In recommendations, you should summarize what you're calling about to the physician.

04:12 So you want to think, what are you asking this physician to do and summarize that for them. This can include your recommendation of what you think is going on, but then you really want to state what you are looking for from the other person.

04:28 'I need you to come see the patient.

04:30 I need you to write an order for a new medication, or I need you to discontinue a certain medication or treatment.' And then you want to read back or repeat what was said to confirm what you heard. So if you received orders, you want to repeat those back to the physician word for word so that the communication is very clear.

04:53 So in unit to unit or facility to facility report, the rationale for report is a little bit different. You want to report a deterioration or improvement of a patient condition, or they may be transferring from after a procedure or test to a new unit.

05:12 So an example would be a medical-surgical unit to an ICU because the patient deteriorated.

05:19 The situation may be the patient was in OR and went to PACU or maybe they're In acute care facility and they're moving to a skilled care facility.

05:30 So what information does this report need to include? You need to explain the change in the patient condition or the procedure or test that was performed.

05:39 You want to explain the patient's outcome and you want to use the ISBAR report to the RN.

05:48 It is the RN's responsibility for completing documentation that will accompany the patient when they discharge, transfer or admitted.

05:57 It can be written or electronic and it differs by facility or unit.

06:03 Examples include copies of the chart and admission orders for client transferred to skilled care.

06:10 Written patient information for patients being admitted from the ED.

06:14 Documentation does not take the place of verbal communication with the facility or with the nurse.

06:22 So to summarize continuity of care, it is interdisciplinary, collaborative and patient -centered. And it leads to care that is safe, high quality, cost effective and makes patients satisfied with their care.

06:39 The RN role combines the role of a case manager in which you are facilitating continuity of care, utilizing resources and providing efficient care, advocating for the client and the family.

06:52 The RN is also providing referrals for care providers, equipment resources, things like physical therapy, home health care, durable medical equipment, education programs, etc.

07:07 In continuity of care, the nurse is also functioning as a discharge.

07:10 In continuity of care, the nurse is also functioning as a discharge planner, where you're assessing the client for their discharge needs, working with other health care providers to coordinate services, educate clients and family, and review discharge summary, prescription, medication and follow-up information. Communication is key to continuity of care.

07:34 ISBAR is the tool used for routine report.

07:39 Contact units and facilities to share information as part of the nursing responsibility and providing written or electronic communication as required is also part of continuity of care.

07:53 This has been continuity of care with Jessica Spellman.