Transcript Promote and Facilitate Safe and Effective Care Transitions

Competency Model for Professional
Rehabilitation Nursing
Behavioral Scenario
for
Competency 2.3: Promote and Facilitate Safe and
Effective Care Transitions
Mary Ullrich, MSN, RN, CRRN &
Kristen L. Mauk, PhD, DNP, RN, CRRN, GCNS-BC, GNP-BC, FAAN
Copyright©2015, Association of Rehabilitation Nurses
Competency 2.3:
Promote and Facilitate Safe and Effective
Care Transitions
Description/Scope: Optimal collaboration and coordination
among clients, families and healthcare professionals to
promote the safe and timely transition across care settings.
Beginner Proficiency
Level Descriptors
Assesses the client and
family regarding cultural
values and health literacy
as applicable to care
transitions
Participates in the
development of an
interprofessional plan for
care transitions
Contributes to the
development and
implementation of the
goals for care transitions
Participates in the care
conference that
evaluates the care
transition plan
Copyright©2015, Association of Rehabilitation Nurses
Behavioral Scenario
Carl is 72 years old and suffered a left middle cerebral artery infarct. He has
a history of heart failure, DM, HTN and obesity. Pre-morbidly, Carl was
inconsistent in keeping his check-up appointments with his physician unless
he felt poorly.
He developed a PE while on the inpatient rehab
unit. He is currently requiring maximum assistance
with his bladder and bowel programs to be
continent. He lived alone prior to the infarct. His
son and daughter-in-law have agreed to take Carl
to their home after discharge.
Copyright©2015, Association of Rehabilitation Nurses
Path 1 – Not Proficient
Carl’s nurse was thinking ahead to discharge and knowing Carl
could not give his own insulin, she taught his son how to
administer the insulin. She provided handouts regarding heart
failure, diabetes, and information regarding his medications. She
provided information to the family regarding Carl’s follow-up
appointments with his physicians. She reported in team
conference that there were no longer any barriers to Carl’s
discharge, as his family teaching had been completed. Carl was
continent of bowel and bladder, and the therapists were working
with the family on transfers.
Copyright©2015, Association of Rehabilitation Nurses
Path 1 – Not Proficient
Observations & Outcomes
1. The rehab nurse did identify some of Carl’s learning needs in preparation for home discharge when
she taught the son how to administer Carl’s insulin to him. Additionally, the nurse provided written
information on his chronic conditions and medications. However, the nurse reported no barriers to
discharge and that the family teaching was complete. This stopped short of meeting the
competencies for a beginning level.
2. In order to master the beginning level of
competency in this domain, the rehab nurse
should have also assessed Carl‘s and his family’s
health literacy, gained more information about
the transition to home and who would be family
caregivers, provided thorough instruction about
Carl’s follow-up care, helped the family to
develop some reasonable short and long-term
goals, and involved any additional team
members for a safer and more effective
transition to the home environment.
Copyright©2015, Association of Rehabilitation Nurses
Path 2 - Proficient
Concerned regarding Carl’s transition to home, his nurse took the time to talk to Carl with
his son and daughter-in-law regarding Carl’s needs once home. Carl had a scheduled follow
up visit with his PCP for 3 weeks after discharge, but transportation was a concern, as his
daughter-in-law felt uncomfortable transferring Carl to a car. Having had a complicated
hospitalization in acute care as well as in the rehab setting, the nurse assisted Carl and his
son in creating a paper Personal Health Record for all of the healthcare providers Carl would
see post discharge. She instructed the family in insulin administration as well as blood
pressure monitoring. She created a list of signs and symptoms for Carl and his family to be
aware of that would warrant a call to the physician or a trip to the ER. Knowing that Carl
uses a urinal for bladder continence, the nurse discussed options for the nighttime hours.
In team conference, Carl’s nurse requested the Home Health RN to follow him for diabetes
and heart failure monitoring. She requested a Home Health Aide to work with Carl’s
daughter-in-law to learn how to provide basic care to Carl. A bedside commode was
requested to assist with bowel continence and PT was asked to help family learn to transfer
Carl to the BSC. She asked the social worker to assist in finding transportation for Carl to his
physicians appointments.
Copyright©2015, Association of Rehabilitation Nurses
Path 2 – Proficient
Observations & Outcomes
1. The rehabilitation nurse who meets the beginner level of competency, as in this scenario,
used all of her resources to provide thorough education in order to assure a smooth
transition to home. She identified the family’s values and concerns, taking time to
address specific needs regarding transferring, medication, monitoring, and follow-up. She
also discussed continence strategies, and involved home health care staff, the PT, and
social worker in securing help at home and transportation to appointments as needed.
2. Intermediate and proficient rehab nurses would additionally engage in activities such as
coordinating and facilitating an interprofessional plan of care as well as using data to
evaluate the effectiveness of care transitions to manage and improve programs at a
systems level.
Copyright©2015, Association of Rehabilitation Nurses
What Did You Observe?
How did the outcomes of this scenario differ?
Proficient Nurse
- The nurse who was competent
at the beginner level identified
some of the challenges Carl
would face with his health
maintenance after discharge.
- She assisted Carl and his family
in problem solving some specific
health concerns.
- The rehab nurse sought the
assistance of team members in
providing resources and training
for the family.
Non-Proficient Nurse
- The non-proficient nurse
provided discharge information to
Carl and his family.
- However, anticipating obstacles
to maintaining his health after
discharge were not addressed.
- The nurse also did not sufficiently
address the health literacy of the
patient and family, nor effectively
communicate additional teaching
and resource needs for a smooth
and safe transition home.
Copyright©2015, Association of Rehabilitation Nurses
Takeaways
The focus of rehabilitation nurses is quality of life for
each individual we care for. It is important to understand
and know our patients and their families so that we can
anticipate future obstacles to health maintenance. By
identifying potential threats to their well being and using
all available resources within the interprofessional team
to facilitate smooth care transitions, we can then provide
our patients and families with the necessary tools and
resources to maintain their quality of life.
Copyright©2015, Association of Rehabilitation Nurses