scholarly journals The Role of Care Coordinator for Children with Complex Care Needs: A Systematic Review

2016 ◽  
Vol 16 (2) ◽  
Keyword(s):  
Systematic Review ◽  
Complex Care ◽  
Care Needs ◽  
Care Coordinator ◽  
Complex Care Needs

scholarly journals The Role of Nutritional Support in Cured/Chronic Patients

Nutrients ◽  
2020 ◽  
Vol 12 (10) ◽  
pp. 3167
Author(s):  
Giovanni Rosti ◽  
Fabrizio Romano ◽  
Simona Secondino ◽  
Riccardo Caccialanza ◽  
Federica Lobascio ◽  
...  
Keyword(s):  
Medical Oncology ◽  
Complex Care ◽  
Care Needs ◽  
Chronic Patients ◽  
Diet And Physical Activity ◽  
Complex Care Needs ◽  
Long Term Survivors ◽  
Near Future

Improvements in Clinical Oncology, due to earlier diagnoses and more efficient therapeutic strategies, have led to increased numbers of long-term survivors, albeit many with chronic diseases. Dealing with the complex care needs of these survivors is now an important part of Medical Oncology. Suitable diet and physical activity regimes will be important in maintaining their health. This paper will review what we know and what we can do in the near future for these patients.

Service Coordinators in the NECC Trial: An RDNS perspective

2000 ◽  
Vol 6 (4) ◽  
pp. 104
Author(s):  
Megan Kerr ◽  
Janine Cramond ◽  
Maggie Scott
Keyword(s):  
Complex Care ◽  
Coordinated Care ◽  
Care Needs ◽  
Nursing Service ◽  
The North ◽  
Improved Outcomes ◽  
Service Coordinators ◽  
North Eastern ◽  
Complex Care Needs

The Royal District Nursing Service (RDNS) became involved in the North-Eastern Coordinated Care Trial in October 1997. The purpose of this was to assist the trial in exploring the hypothesis, that for people with chronic or complex care needs, care coordination will provide improved outcomes at the same or a reduced cost. There are a number of areas, which help to clarify the process involved in the trial and the benefits for clients: how the coordinators were chosen; the role of the Care and Service Coordinators: benefits experienced by the professionals; benefits experienced by clients: and discussion points.

scholarly journals The role of the registered nurse in supporting frailty in care homes

2019 ◽  
Vol 28 (13) ◽  
pp. 833-837 ◽  
Author(s):  
Lynn Craig
Keyword(s):  
Care Delivery ◽  
Nutrition Status ◽  
Complex Care ◽  
Care Needs ◽  
Crucial Component ◽  
Unplanned Admissions ◽  
Complex Care Needs ◽  
The Impact ◽  
Negative Health Outcomes

People in nursing and residential homes are more likely to suffer frailty. Registered nurses are a crucial component of the care delivery service and can offer support to patients who have complex care needs and comorbidities and are at risk of unplanned admissions to secondary care. This article explores frailty and the role of the nurse in assessing for frailty. Three aspects of patient care—nutrition status, polypharmacy and exercise and cognitive function—are discussed as areas where nurses can target their interventions in order to support those considered as frail, aiming to reduce the impact of frailty and negative health outcomes.

Health Status Transitions in Community-Living Elderly with Complex Care Needs

2011 ◽  
pp. 223-247
Author(s):  
Louise Lafortune ◽  
François Béland ◽  
Howard Bergman ◽  
Joël Ankri
Keyword(s):  
Health Status ◽  
Community Living ◽  
Complex Care ◽  
Care Needs ◽  
Complex Care Needs

scholarly journals People with an intellectual disability in the discourse of chronic and complex conditions: an invisible group?

2008 ◽  
Vol 32 (3) ◽  
pp. 405 ◽  
Author(s):  
Linda Goddard ◽  
Patricia M Davidson ◽  
John Daly ◽  
Sandra Mackey
Keyword(s):  
Health Care ◽  
Intellectual Disability ◽  
Chronic Conditions ◽  
Health Professions ◽  
Disability Services ◽  
Complex Care ◽  
Competency Development ◽  
Care Needs ◽  
Complex Care Needs ◽  
Respiratory Conditions

People with an intellectual disability and their families experience poorer health care compared with the general population. Living with an intellectual disability is often challenged by coexisting complex and chronic conditions, such as gastrointestinal and respiratory conditions. A literature review was undertaken to document the needs of this vulnerable population, and consultation was undertaken with mothers of children with disabilities and with professionals working within disability services for people with an intellectual disability and their families. Based on this review, there is a need to increase the profile of people with an intellectual disability in the discourse surrounding chronic and complex conditions. Strategies such as guideline and competency development may better prepare health professions to care for people with disabilities and chronic and complex care needs and their families.

scholarly journals Building a Digital Bridge to Support Patient-Centered Care Transitions From Hospital to Home for Older Adults With Complex Care Needs: Protocol for a Co-Design, Implementation, and Evaluation Study (Preprint)

2020 ◽  
Author(s):  
Carolyn Steele Gray ◽  
Terence Tang ◽  
Alana Armas ◽  
Mira Backo-Shannon ◽  
Sarah Harvey ◽  
...  
Keyword(s):  
Older Adults ◽  
Phase 1 ◽  
Care Transitions ◽  
Self Management ◽  
Complex Care ◽  
Phase 2 ◽  
Care Needs ◽  
Centered Care ◽  
Hospital To Home ◽  
Complex Care Needs

BACKGROUND Older adults with multimorbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Transition periods mark vulnerable moments in care for individuals with CCN. Poor communication and incomplete information transfer between clinicians and organizations involved in the transition from hospital to home can impede access to needed support and resources. Establishing digitally supported communication that enables person-centered care and supported self-management may offer significant advantages as we support older adults with CCN transitioning from hospital to home. OBJECTIVE This protocol outlines the plan for the development, implementation, and evaluation of a Digital Bridge co-designed to support person-centered health care transitions for older adults with CCN. The Digital Bridge builds on the foundation of two validated technologies: Care Connector, designed to improve interprofessional communication in hospital, and the electronic Patient-Reported Outcomes (ePRO) tool, designed to support goal-oriented care planning and self-management in primary care settings. This project poses three overarching research questions that focus on adapting the technology to local contexts, evaluating the impact of the Digital Bridge in relation to the quadruple aim, and exploring the potential to scale and spread the technology. METHODS The study includes two phases: workflow co-design (phase 1), followed by implementation and evaluation (phase 2). Phase 1 will include iterative co-design working groups with patients, caregivers, hospital providers, and primary care providers to develop a transition workflow that will leverage the use of Care Connector and ePRO to support communication through the transition process. Phase 2 will include implementation and evaluation of the Digital Bridge within two hospital systems in Ontario in acute and rehab settings (600 patients: 300 baseline and 300 implementation). The primary outcome measure for this study is the Care Transitions Measure–3 to assess transition quality. An embedded ethnography will be included to capture context and process data to inform the implementation assessment and development of a scale and spread strategy. An Integrated Knowledge Translation approach is taken to inform the study. An advisory group will be established to provide insight and feedback regarding the project design and implementation, leading the development of the project knowledge translation strategy and associated outputs. RESULTS This project is underway and expected to be complete by Spring 2024. CONCLUSIONS Given the real-world implementation of Digital Bridge, practice changes in the research sites and variable adherence to the implementation protocols are likely. Capturing and understanding these considerations through a mixed-methods approach will help identify the range of factors that may influence study results. Should a favorable evaluation suggest wide adoption of the proposed intervention, this project could lead to positive impact at patient, clinician, organizational, and health system levels. CLINICALTRIAL ClinicalTrials.gov NCT04287192; https://clinicaltrials.gov/ct2/show/NCT04287192 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/20220

Family-Centered, Community-Based, Coordinated Care for Children With Special Needs

PEDIATRICS ◽  
1989 ◽  
Vol 83 (6) ◽  
pp. 1061-1061
Author(s):  
RICHARD M. NARKEWICZ
Keyword(s):  
Task Force ◽  
Case Manager ◽  
Community Services ◽  
Coordinated Care ◽  
Care Needs ◽  
Care Coordinator ◽  
Community Based ◽  
The Family ◽  
Family Centered

Assuring that all children with special health care needs have access to family-centered, community-based, coordinated care, as described by Brewer et al in this issue of Pediatrics, is a timely and commendable goal that the American Academy of Pediatrics (AAP) shares. Pediatricians have a major role to play in the shaping of these services and assuring their accessibility by the children who need them. Last winter, the AAP held three task force meetings to discuss the role of pediatricians vis-á-vis the case manager/care coordinator. A consensus emerged from these meetings that a variety of roles should be available to pediatricians, depending upon the child's diagnosis, the pediatrician's training and interest, the skills of the family, and the community services available.

scholarly journals Do general practice management and/or team care arrangements reduce avoidable hospitalisations in Central and Eastern Sydney, Australia?

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Heidi Welberry ◽  
Margo Linn Barr ◽  
Elizabeth J. Comino ◽  
Ben F. Harris-Roxas ◽  
Elizabeth Harris ◽  
...  
Keyword(s):  
General Practice ◽  
Data Collection ◽  
Health Service ◽  
Baseline Period ◽  
Health Service Utilisation ◽  
Service Utilisation ◽  
Complex Care ◽  
Care Needs ◽  
Team Care ◽  
Complex Care Needs

Abstract Background The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years. Methods This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006–2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage. Results Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years. Conclusions The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.

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