Community based healthcare systems have proposed the concept of continuum of care. It is a concept of a system that successfully guides and tracks various patients over a period of time through a comprehensive array of health services that would be spanning at all levels and intensity of care (Pittman et al., 2015). This concept is also believed to cover the delivery of healthcare over a period of time and might also refer to care services and monitoring starting from time of birth to that of death.
Accountable care organisations are considered as newer concepts where groups of healthcare professionals, doctors as well as other healthcare providers are seen to come together voluntarily for giving coordinated high quality and safe care for their Medicare patients (Fraher et al., 2015). They have the main aim that people get right kind of services at the right time without duplication of any forms of services and prevention of medical errors.
Medical home:
This can be described as the model or philosophy of primary care that nurses should incorporate in their practices. This model of care should be should be patient centred, team-based, comprehensive, accessible, coordinated and should be focusing on quality and safety. Healthcare professionals need to meet patients where they are present that might include simpler to most complex situations (Hain & Fleck, 2014). It can be considered as a model aiming to achieve primary care excellence so that right care is given at right time and right place and in the best manner that suits the needs of patient.
Nurse managed health clinics:
These are community based primary healthcare centres that usually work under the leadership of advanced practice nurses. They are mainly seen to emphasize on health educations, disease preventions, healthy promotion and many others for developing the quality of life of people who are mostly undeserved, face discrimination as well as that of the ordinary people (Adaji et al., 2018).
Mrs Lisa was of the opinion that the coming years would witness huge demands on the number of nurses presently working in organisations. The generation is experiencing longer livelihood of people whose life expectancy had increased because of better medicine availability and treatment options that prevent death. However, she had rightly identified the trend that although more and more people are living, their quality of life is not managed effectively and hence they are seen to admit to hospitals with critical cases of unmanaged chronic disorders. Huge expenditure of healthcare resources on their treatment takes place that provide pressure on healthcare funding (Freidberg et al., 2014). Therefore, she was of the opinion that preventative care treatment plans should be the main motto of present day nurses. Her opinion was more or less similar to my thinking procedures. More number of nurses need to be appointed in the primary healthcare centres as these centres are the first areas where patients visit for help regarding their health issues. Therefore, in these sessions only, nurses need to fulfil the role of health educators and develop health literacy among patients. They need to make them aware of the different risks and lifestyle factors that they need to manage in order to live healthy lives. I believe this would automatically reduce the chances of unmanaged chronic ailments and hence reduce hospitalisation rates.
Mr. Samuel was seen to be praising the new role of nurses as care coordinators which I had not discussed in the presentation. He told me that he had liked the presentation and his beliefs and ideas about nurse’s role in the new healthcare transformation system are absolutely perfect and on-track. The community healthcare centres are now allocating complex care coordinators, chronic care managers, care mangers and similar positions. His discussion had enlightened within me a new concept that I had not discussed in my presentation but aligned with the different aspects of healthcare transformation that I discussed. These people are nurses who are seen to manage patients with chronic conditions and help them to stay well and lead quality lives as far long as possible. He opined that job role of such nurses comprise of formulating discharge plans and also ensuring that patients are following through their appointments and adhere to medication schedules. He convinced me that as the new system of healthcare am trying to make professionals work in ways by which they can reduce readmissions and lower the costs under the umbrella of bundled payments, the role of care coordinators have evolved. In the present generation, I have also noticed that care coordinators take charge of managing care of patient from surgery to 90 days post acute treatment. Studies have already proved that registered nurse who undertakes such roles can provide more effective care for a diabetes and high blood pressure patient than these patients who are managed by physicians alone (Cene et al., 2016). Thereby such nurses prevent chances of patients getting readmitted due to poor post discharge self-management and care.
Miss Susanne was seen to be supporting the concept of medical home as her feedback revealed that this concept has the ability to provide best quality care to patient and making them responsible about their own care. These would reduce chances of readmission to healthcare centres along with preventable health disorders and hence prevent huge flow of healthcare resources. She supported my opinion regarding the medical home concept. She suggested that “patient centred” attributes help in developing an effective partnership among patients, families and professionals. This ensures that ultimate healthcare decision that would be taken would respect the wants, needs and preferences or patients. This would develop their accessibility to healthcare services. They would also be educating and supporting patient so that they can make decisions and participate in their own care. This would increase the responsibility of patients and make them feel empowered, this would help in making them adhered to their own treatment and hence readmissions as well as unmanaged health conditions would be prevented handled effectively (Pittman et al., 2015). Comprehensive, coordinated and accessible care by nurses along with commitment and safety would help patients to get cured through community services only and hence healthcare resources can be saved. Personalised care plans, medication reviews, coaching patient and giving them advice, supporting and encouraging patients are some of the actions from under medical home concept. This would help in effective healthcare transformation and protect people.
References:
Adaji, A., Melin, G. J., Campbell, R. L., Lohse, C. M., Westphal, J. J., & Katzelnick, D. J. (2018). Patient-centered medical home membership is associated with decreased hospital admissions for emergency department behavioral health patients. Population health management, 21(3), 172-179.
Bodenheimer, T., & Mason, D. (2016, June). Registered nurses: Partners in transforming primary care. In Proceedings of a conference sponsored by the Josiah Macy Jr. Foundation in June.
Boswell, C. & Cannon, S., (2018). Introduction to nursing research: Incorporating evidence-based practice. Jones & Bartlett Publishers.
Cené, C. W., Johnson, B. H., Wells, N., Baker, B., Davis, R., & Turchi, R. (2016). A Narrative Review of Patient and Family Engagement: The “Foundation” of the Medical Home. Medical care, 54(7), 697.
Duffy, J. R. (2018). Quality Caring in Nursing and Health Professions: Implications for Clinicians, Educators, and Leaders. Springer Publishing Company.
Fraher, E., Spetz, J., & Naylor, M. D. (2015). Nursing in a transformed health care system: New roles, new rules.
Friedberg, M. W., Schneider, E. C., Rosenthal, M. B., Volpp, K. G., & Werner, R. M. (2014). Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care. Jama, 311(8), 815-825.
Hain, D., & Fleck, L. (2014). Barriers to nurse practitioner practice that impact healthcare redesign. OJIN: The Online Journal of Issues in Nursing, 19(2).
Pittman, P., Bass, E., Hargraves, J., Herrera, C., & Thompson, P. (2015). The future of nursing: monitoring the progress of recommended change in hospitals, nurse-led clinics, and home health and hospice agencies. Journal of Nursing Administration, 45(2), 93-99.
Salmond, S. W., & Echevarria, M. (2017). Healthcare transformation and changing roles for nursing. Orthopedic nursing, 36(1), 12.
Young, H. M., Bakewell-Sachs, S., & Sarna, L. (2017). Nursing practice, research and education in the west: the best is yet to come. Nursing research, 66(3), 262-270.
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