In reevaluating the data and experience of Mr. C’s transition, the complex adaptive system should be used to better understand his potential health outcome as it generates a broader and more integrative framework. In combining the transition theory and complexity science, we can better support our roles as health care providers. Perspectives, relationships, rules, sense-making, emergence, culture, and multidisciplinary nature of health care are all concepts brought forth by complexity science. From the pictured integrated model, it seems that there is perfect overlay and integration of theories and further develops the concept that new perspectives and added dynamics will always affect all of those involved no matter how great or small. For …show more content…
It provides the fluidity and multidimensional complexity that is definitive of any patient’s experience that a nurse might play a part. In both experiences of transitions and the theory that attempts to understand it evolve and emerge, the gap seems to be in the implementation due to system breakdown. We are all aware that there is fragmented care, and it’s not for lack of concern by HCP and policy makers alike (Geary and Schumacher 2012). The health care system has been transforming to allow for more positive health outcomes across the continuum and attempts to identify and close the gap on the health disparities. Care coordination seems to be the missing link with not only Mr. C, but with many of the clients we have met throughout the term. Care coordination has been identified by the Institute of Medicine as one of the key strategies for potentially closing this gap. A working definition formed by the Agency for Healthcare Research and Quality reveals that care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care (www.ahrq.gov). In a critical analysis of Quality Improvement Strategies, they found that care coordination for patients with diabetes showed improved outcomes, and that both disease management and case management improved glycemic control (Shojania, McDonald, Wachter, and Owens
The developmental stage of a patient is of importance to nursing care because knowledge of human growth and development is basic to the healthcare of individuals across the life span. Thus, in order for healthcare professionals to properly and appropriately care for their patients, an understanding of the different stages of development and tasks to be accomplished in each stage is necessary.
Teamwork and collaboration in healthcare delivery are “top of the mind” issues and government reports have called for improved collaboration among healthcare professionals as a key strategy in healthcare renewal (Canadian Health Services Research Foundation, 2006, p. 10). The term team defines a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes and who manage their relationships across organizational borders (Canadian Health Services Research Foundation, 2006, p. 8). Moreover, the Canadian Nurses Association (CNA) believes that interprofessional collaborative models for health service delivery are critical for improving access to client-centred health care in Canada (CNA, n.d. p. 1). This paper will discuss a care scenario, Canadian Interprofessional Health Collaborative (CIHC) framework, TeamSTEPPS framework analysis, strategies to promote collaborative leadership and interprofessional communication with outcomes, strengths and limitations of
When everyone is working on the patient making progress in different directions, the patient will be completely lost and eventually lose confident in the caretakers. Atul Gawande describes this through a car analogy in which a vehicle is made using the best features of different manufactures. He describes the care as, “A very expensive pile of junk that does not go anywhere… It’s not a system.” Everyone has a different skill set that if used in a collaborative way the medical team will be able to identify the problem more efficiently, recognize areas of failure and address them in a timely manner, and lastly with an ordered system the patient-physician relationship will form a stronger bond. With a more ordered work environment, the health care professionals will be able to attend to the patient more keeping them informed and be able to interact with the physician more frequently. Just to show how well this order work Gawande noticed that with an implemented checklist complication rates fell 35 percent and the death rates decrease 47 percent far more than any drug. This will allow the physician and nurses to not only help the patient with physical treatments such as medicine but psychologically as
This section discusses health psychology and behavioral medicine, making positive life changes, resources for effective life change, controlling stress, behaving, and your good life. Health psychology emphasizes psychology’s role in establishing and maintaining health and preventing and treating illness. It reflects the belief that lifestyle choices, behaviors, and psychological characteristics can play important roles in health. The mind is responsible for much of what happens in the body, it is not the only factor, the body may influence the mind as well. Making positive life changes include health behaviors- practices that have an impact on physical well being. The stages of change model describes the process by which individuals give up bad habits and adopt healthier lifestyles. The model has five stages: precontemplation, contemplation, preparation/ determination, action/ willpower, and
In the article “Time to learn: Understanding patient-centered care,” Rinchen Pelzang clarifies not only what patient-centered care means but what it looks like when implemented. These clarifications are necessary because although most healthcare setting advocate patient-centered care, with no clear definition. Pelzang mentions this as one of the most prominent barriers to PCC, the misinterpretation of the concept. In order to combat this barrier proper education and emphasis on communication are needed. When this isn’t the case, “the failure to recognize nurse-patient communication as an essential component of nursing care is the greatest barrier to effective communication” (Pelzang, 2010). Collaborative care and
Bridges’ model describes three stages that people are likely to experience within a transition that I have personally gone through
The demand of a constantly developing health service has required each professional to become highly specialised within their own field. Despite the focus for all professionals being on the delivery high quality care (Darzi, 2008); no one profession is able to deliver a complete, tailored package. This illustrates the importance of using inter-professional collaboration in delivering health care. Patient centric care is further highlighted in policies, emphasising the concept that treating the illness alone whilst ignoring sociological and psychological requirements on an individual is no longer acceptable. Kenny (2002) states that at the core of healthcare is an agreement amongst all the health professionals enabling them to evolve as the patient health requirements become more challenging but there are hurdles for these coalitions to be effective: for example the variation in culture of health divisions and hierarchy of roles. Here Hall (2005) illustrates this point by stating that physicians ignore the mundane problems of patients, and if they feel undervalued they do not fully participate with a multidisciplinary team.
Today, many Americans face the struggle of the daily hustle and bustle, and at times can experience this pressure to rush even in their medical appointments. Conversely, the introduction of “patient-centered care” has been pushed immensely, to ensure that patients and families feel they get the medical attention they are seeking and paying for. Unlike years past, patient centered care places the focus on the patient, as opposed to the physician.1 The Institute of Medicine (IOM) separates patient centered care into eight dimensions, including respect, emotional support, coordination of care, involvement of the family, physical comfort, continuity and transition and access to care.2
Care coordination will be essential to help maintain the health of the client. Care coordination is the process that transpires between
There are many ways to categorize illness and disease; one of the most common is chronic illness. Many chronic illnesses have been related to altered health maintenance hypertension and cardiovascular diseases are associated with diet and stress, deficient in exercise, tobacco use, and obesity (Craven 2009). Some researchers define the chronic illness as diseases which have long duration and generally slow development (WHO 2013); it usually takes 6 month or longer than 6 month, and often for the person's life. It has a sluggish onset and eras of reduction for vanishing the symptoms and exacerbation for reappear the symptoms. Some of chronic illness can be directly life-threatening. Others remain over time and need intensive management, such as diabetes, so chronic illness affects physical, emotional, logical, occupational, social, or spiritual functioning. Chronic diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, all of these diseases are the cause of mortality in the world, representing 63% of all deaths. So a chronic illness can be stressful and may change the way a person l...
Agency for HealthCare Research and Quality explained care coordination is a key strategy for effectiveness, safety and efficiency of the American health care system. Coordination care need to be well designed meaning it equipped with the right people that can lead to better outcome for patients, providers and payers (Agency for Healthcare Research and Quality, 2016).
The chronic care model calls for an organizational change in the way individuals with illnesses are cared for, and the involvement of nurses, social workers and patients themselves. The challenge is moving in an effective way of improving quality from research carried out predominantly in health maintenance organizations to the mainstream of health care practice (Wielawski, 2006). Wagner’s explanation is to substitute the customary physician-centric office structure with one that supports clinical teamwork in association with the patient. The notion spreads outside the health care organization to collaborative associations in the community. Wagner et al. (2001) termed this approach the “chronic care model.” With this model, physicians, nurses, case managers, dieticians, and patient educators
Collaboration is the foundation to success in any team. In the healthcare setting, interprofessional collaboration (IC) has been a significant trademark among numerous highly successful innovations. Collaboration between nurses and other healthcare providers improves the quality of care, coordination, and communication between the team leading to increased patient safety. Working in a team to achieve common goals implies open communication, respect for others, mutual trust, and honesty. The purpose of this paper is to discuss the meaning of interprofessional collaboration, its implications for practice, describe the role of IC in the provision of patient and family-centered care,
The demands on health care providers to provide the best quality care for patients is increasing. With added responsibilities and demands on our health care workers, it is hard not become overwhelmed and forget the reason and purpose of our profession. However, there is a way where all professionals can meet and come together for a common cause, which is the patient. A new approach in patient care is coming of age. This approach allows all health care professionals to collaborate and explore the roles of other professions in the hope of creating a successful health care team. This approach is referred to as the Interprofessional Collaboration Practice (IPC). To become an effective leader and follower, each professions will need to work together
Rosen, C. S. (2000). Is the sequencing of change processes by stage consistent across health problems? A meta-analysis. Health Psychology, 19(6), 593-604.