STAFFINGSTAFFING

AND NURSINGAND NURSING

CARE DELIVERY CARE DELIVERY MODELSMODELS

Nursing care delivery Nursing care delivery modelsmodels

•Nursing care delivery Nursing care delivery models, also called care models, also called care delivery systems or patient delivery systems or patient care delivery models, detail care delivery models, detail the way task assignments, the way task assignments, responsibility, and responsibility, and authority are structured to authority are structured to accomplish patient careaccomplish patient care. .

Nursing care Nursing care delivery modelsdelivery models

The nursing care delivery The nursing care delivery model describes model describes

1.1. which health care worker is which health care worker is going to perform what going to perform what tasks, tasks,

2.2. who is responsible, and who is responsible, and 3.3. who has the authority to who has the authority to

make decisions.make decisions.

Nursing care Nursing care delivery modelsdelivery models

•The basic premise of nursing The basic premise of nursing care delivery models is that care delivery models is that the number and type of the number and type of caregivers are closely caregivers are closely matched to patient care matched to patient care needs to provide quality care needs to provide quality care in the most cost-effective in the most cost-effective manner possible.manner possible.

Nursing care Nursing care delivery modelsdelivery models

•The four classic nursing care The four classic nursing care delivery models used during delivery models used during the past five decades are the past five decades are

•(1) total patient care, (1) total patient care, •(2) functional nursing, (2) functional nursing, •(3) team nursing, and (3) team nursing, and •(4) primary nursing. (4) primary nursing.

Total Patient CareTotal Patient Care•The oldest method of organizing The oldest method of organizing

patient care is total patient care, patient care is total patient care, sometimes referred to as case sometimes referred to as case nursing. In total patient care nurses nursing. In total patient care nurses are responsible for planning, are responsible for planning, organizing, and performing all care, organizing, and performing all care, including personal hygiene, including personal hygiene, medications, treatments, emotional medications, treatments, emotional support, and education required for support, and education required for their assigned group of patients their assigned group of patients during the assigned shift.during the assigned shift.

Total Patient CareTotal Patient Care• Registered Registered Registered Registered

RegisteredRegistered• nurse 8-hour nurse8-hour nurse8-nurse 8-hour nurse8-hour nurse8-

hourhour• shift shift shiftshift shift shift• • Patient carePatient care• The registered nurse The registered nurse • plans, organizes, plans, organizes, • and performs all care.and performs all care.• The total patient care (case method) delivery The total patient care (case method) delivery

model.model.

Functional NursingFunctional Nursing• In the functional nursing method of In the functional nursing method of

patient care delivery, staff members are patient care delivery, staff members are assigned to complete certain tasks for a assigned to complete certain tasks for a group of patients rather than care for group of patients rather than care for specific patients. For example, the RN specific patients. For example, the RN performs all assessments and administers performs all assessments and administers all intravenous medications; the LVN/LPN all intravenous medications; the LVN/LPN gives all oral medications; and the gives all oral medications; and the assistant performs hygiene tasks and takes assistant performs hygiene tasks and takes vital signs. A charge nurse makes the vital signs. A charge nurse makes the assignments and coordinates the care. assignments and coordinates the care.

Functional NursingFunctional Nursing

• Nurse ManagerNurse Manager

• LVN/LPNLVN/LPN RN RN Nurse aide Nurse Nurse aide Nurse aideaide

• PO Meds Assessments Vital signsPO Meds Assessments Vital signs HygieneHygiene

• TreatmentsTreatments Care plans Care plans Hygiene Hygiene StockingStocking

• Assignet Patient GroupAssignet Patient Group

• The functional nursing care delivery modelThe functional nursing care delivery model

Team NursingTeam Nursing• In team nursing the RN functions as In team nursing the RN functions as

a team leader and coordinates a a team leader and coordinates a small group (no more than four or small group (no more than four or five) of ancillary personnel to five) of ancillary personnel to provide care to a small group of provide care to a small group of patients. "patients. "As coordinator of the team, As coordinator of the team, the registered nurse is responsible for the registered nurse is responsible for knowing the condition and needs of all knowing the condition and needs of all the patients assigned to the team, and the patients assigned to the team, and for planning the care of each patient" for planning the care of each patient" (Marquis and Huston, 2000).(Marquis and Huston, 2000).

Team NursingTeam Nursing•The team leader is responsible for The team leader is responsible for

encouraging a cooperative encouraging a cooperative environment and maintaining clear environment and maintaining clear communication between all team communication between all team members. members.

•The team leader's duties include The team leader's duties include planning care, assigning duties, planning care, assigning duties, directing and assisting team members, directing and assisting team members, giving direct patient care, teaching, giving direct patient care, teaching, and coordinating patient activities. and coordinating patient activities.

Team NursingTeam Nursing• Nurse ManageNurse Manage

• RN Team Leader RN Team RN Team Leader RN Team LeaderLeader

• RN RNRN RN• LVNs/LPNs LVNs/LPNsLVNs/LPNs LVNs/LPNs• Nursing assistantsNursing assistants Nursing Nursing

assistantsassistants• Assigned patient Assigned patient Assigned Assigned

patient patient • group groupgroup group

• Team nursing modelTeam nursing model

Advantages of the Team Advantages of the Team Nursing ModelNursing Model

• 1. High-quality, comprehensive care 1. High-quality, comprehensive care can be provided with a relatively can be provided with a relatively high proportion of ancillary staff.high proportion of ancillary staff.

• 2. Each member of the team is able 2. Each member of the team is able to participate in decision making and to participate in decision making and problem solving.problem solving.

• 3. Each team member is able to 3. Each team member is able to contribute his or her own special contribute his or her own special expertise or skills in caring for the expertise or skills in caring for the patient. patient. (Marquis and Huston, 2000).(Marquis and Huston, 2000).

Disadvantages of the Team Disadvantages of the Team Nursing ModelNursing Model

• 1. 1. Continuity of care may suffer if the Continuity of care may suffer if the daily team assignments vary and the daily team assignments vary and the patient is confronted with many different patient is confronted with many different caregivers.caregivers.

• 2. The team leader may not have the 2. The team leader may not have the leadership skills required to effectively leadership skills required to effectively direct the team and create a "team direct the team and create a "team spirit."spirit."

• 3. Insufficient time for care planning and 3. Insufficient time for care planning and communication leads to unclear goals. communication leads to unclear goals. Therefore responsibilities and care may Therefore responsibilities and care may become fragmented.become fragmented.

TEAM NURSINGTEAM NURSING•Team nursing is an effective, efficient Team nursing is an effective, efficient

method of patient care delivery and method of patient care delivery and has been used in most inpatient and has been used in most inpatient and outpatient health care settings. outpatient health care settings.

•The team leader must have strong The team leader must have strong clinical skills, good communication clinical skills, good communication skills, delegation ability, decision-skills, delegation ability, decision-making ability, and the ability to making ability, and the ability to create a cooperative working create a cooperative working environment. environment.

Modular NursingModular Nursing• Modular nursing is a modification of team Modular nursing is a modification of team

nursing and focuses on the patient's nursing and focuses on the patient's geographic location for staff assignments. geographic location for staff assignments.

• The patient unit is divided into modules The patient unit is divided into modules or districts, and the same team of or districts, and the same team of caregivers is assigned consistently to the caregivers is assigned consistently to the same geographic location. same geographic location.

• Each location, or module, has an RN Each location, or module, has an RN assigned as the team leader, and the assigned as the team leader, and the other team members may include other team members may include LVNs/LPNs and UAP LVNs/LPNs and UAP (Yoder Wise, 1999).(Yoder Wise, 1999).

Modular NursingModular Nursing

• The concept of modular nursing calls for a The concept of modular nursing calls for a smaller group of staff providing care for a smaller group of staff providing care for a smaller group of patients. smaller group of patients.

• The goal is to increase the involvement of The goal is to increase the involvement of the RN in planning and coordinating care. the RN in planning and coordinating care.

• Communication is more efficient among a Communication is more efficient among a smaller group of team members smaller group of team members (Marquis and (Marquis and Huston, 2000). Huston, 2000).

• To maximize efficiency, each designated To maximize efficiency, each designated module should contain all the supplies module should contain all the supplies needed by the staff to perform patient care. needed by the staff to perform patient care.

Partnership ModelPartnership Model•The partnership model, sometimes The partnership model, sometimes

referred to as co-primary nursing, referred to as co-primary nursing, is a modification of primary nursing is a modification of primary nursing and was designed to make more and was designed to make more efficient use of the RN. efficient use of the RN.

• In the partnership model the RN is In the partnership model the RN is partnered with an LVN/LPN or partnered with an LVN/LPN or UAP, and the pair work together UAP, and the pair work together consistently to care for an assigned consistently to care for an assigned group of patients.group of patients.

CASE MANAGEMENTCASE MANAGEMENT• Evolution of Case ManagementEvolution of Case Management• Case management is a model of care Case management is a model of care

delivery in which an RN case manager delivery in which an RN case manager coordinates the patient's care coordinates the patient's care throughout the course of an illness. throughout the course of an illness.

• The concept of case management was The concept of case management was first introduced in the 1970s by first introduced in the 1970s by insurance companies as a method to insurance companies as a method to monitor and control expensive health monitor and control expensive health insurance claims, usually created by a insurance claims, usually created by a catastrophic accident or illness catastrophic accident or illness (More and (More and Mandell, 1997). Mandell, 1997).

CASE MANAGEMENTCASE MANAGEMENT

•Today, virtually every major health Today, virtually every major health insurance company has a case insurance company has a case management program to direct and management program to direct and manage the use of health care manage the use of health care services for their clients. services for their clients.

•Case management by payer Case management by payer organizations (e.g., health insurance organizations (e.g., health insurance companies, health maintenance companies, health maintenance organizations [HMOs]) is known as organizations [HMOs]) is known as external case management.external case management.

CASE MANAGEMENTCASE MANAGEMENT• The ANA has defined nursing case management The ANA has defined nursing case management

as "a dynamic and systematic collaborative as "a dynamic and systematic collaborative approach to providing and coordinating health approach to providing and coordinating health care services to a defined population. It is a care services to a defined population. It is a participative process to identify and facilitate participative process to identify and facilitate options and services for meeting individuals' options and services for meeting individuals' health needs, while decreasing fragmentation health needs, while decreasing fragmentation and duplication of care and enhancing quality, and duplication of care and enhancing quality, cost-effective clinical outcomes. The framework cost-effective clinical outcomes. The framework for nursing care management includes five for nursing care management includes five components: assessment, planning, components: assessment, planning, implementation, evaluation, and interaction" implementation, evaluation, and interaction" (ANCC, 2001, p. 1). (ANCC, 2001, p. 1).

Components of Case Components of Case ManagementManagement

• Assessment. Assessment. • • • Review the client's history and current Review the client's history and current

statusstatus• • • Perform comprehensive health Perform comprehensive health

assessmentassessment• • • Identify available resources and support Identify available resources and support

system (e.g., individual, family, financial, system (e.g., individual, family, financial, health insurance, community)health insurance, community)

• • • Identify barriers to accessing necessary Identify barriers to accessing necessary treatment (e.g., lack of health insurance treatment (e.g., lack of health insurance coverage; no family support)coverage; no family support)

Components of Case Components of Case ManagementManagement

• Assessment. Assessment. • Identify health promotion and disease Identify health promotion and disease

prevention opportunitiesprevention opportunities• • • Identify adherence patterns, Identify adherence patterns,

educational needs, and ability to learneducational needs, and ability to learn• • • Determine potential for overuse or Determine potential for overuse or

under use of resourcesunder use of resources• • • Find, appraise, and use research Find, appraise, and use research

findings as the basis for treatment findings as the basis for treatment decisions (evidence-based practice)decisions (evidence-based practice)

Components of Case Components of Case ManagementManagement

• Planning. Planning. • Prioritize needs and set realistic, Prioritize needs and set realistic,

measurable goals and outcomesmeasurable goals and outcomes• Identify realistic treatment optionsIdentify realistic treatment options• Coordinate various providers involved in the Coordinate various providers involved in the

plan of care (e.g., physician, physical plan of care (e.g., physician, physical therapist, dietitian)therapist, dietitian)

• Determine appropriate levels of care and Determine appropriate levels of care and realistic treatment settings (e.g., home, realistic treatment settings (e.g., home, long-term care, rehabilitation facility)long-term care, rehabilitation facility)

• Identify and address gaps in careIdentify and address gaps in care• Ensure continuity of careEnsure continuity of care• Negotiate and manage financial aspects of Negotiate and manage financial aspects of

carecare

Components of Case Components of Case ManagementManagement

• ImplementationImplementation• Ensure implementation of the care plan Ensure implementation of the care plan

in a safe, timely and cost-effective in a safe, timely and cost-effective mannermanner

• Coordinate services and referrals to Coordinate services and referrals to providers or agenciesproviders or agencies

• Ensure compliance with federal, state, Ensure compliance with federal, state, and local regulations and standardsand local regulations and standards

• Use appropriate community resourcesUse appropriate community resources• Document progress toward achieving Document progress toward achieving

goals and outcomesgoals and outcomes• Accept accountability for implementation Accept accountability for implementation

of the care planof the care plan

Components of Case Components of Case ManagementManagement

• EvaluationEvaluation• • • Measure clinical goals, functional Measure clinical goals, functional

improvement, satisfaction with services improvement, satisfaction with services and cost-benefit of treatment planand cost-benefit of treatment plan

• • • Is/was the plan of care realistic, Is/was the plan of care realistic, collaborative, and mutually beneficial to all collaborative, and mutually beneficial to all involved?involved?

• • • Are/were the established time frames Are/were the established time frames realistic?realistic?

• • • Are/were the best possible and most cost-Are/were the best possible and most cost-effective treatments used?effective treatments used?

• • • Are/were individual educational Are/were individual educational opportunities maximized?opportunities maximized?

Components of Case Components of Case ManagementManagement

• InteractionInteraction• • • Interact on a daily basis with diverse groups Interact on a daily basis with diverse groups

of people: client, family members, and of people: client, family members, and significant others; health care team members; significant others; health care team members; payer representatives; representatives from payer representatives; representatives from other health care agencies and community other health care agencies and community organizationsorganizations

• • • Motivate diverse groups to cooperate, Motivate diverse groups to cooperate, collaborate, and work in the best interest of collaborate, and work in the best interest of the clientthe client

• • • Use good communication, negotiation, Use good communication, negotiation, facilitation, and documentation skills.facilitation, and documentation skills.

CASE MANAGEMENTCASE MANAGEMENT• Nursing case management in a health Nursing case management in a health

care facility is a supplemental form of care facility is a supplemental form of nursing care delivery and does not take nursing care delivery and does not take the place of the nursing care delivery the place of the nursing care delivery model in place to provide direct patient model in place to provide direct patient care. care.

• Case management is not needed for Case management is not needed for every patient in a health care facility every patient in a health care facility and generally is reserved for the and generally is reserved for the chronically ill, seriously ill or injured, chronically ill, seriously ill or injured, and long-term, high-cost cases.and long-term, high-cost cases.