Practice of Nursing, Concepts of Continuity, ACO, Medical Homes, and Nurse-managed Clinics

Benchmark Assignment: Evolving Practice of Nursing and Patient Care Delivery Models
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Benchmark Assignment: Evolving Practice of Nursing and Patient Care Delivery Models
The nurse colleagues pointed out that the focus of healthcare in general is shifting from acute care in hospitals towards primary care within community-based settings. They added that as this shift takes place, disease prevention instead of response to disease would play an ever-bigger role going forward. Their impressions are consistent with what I have researched about health reform. Cardillo (2013) noted that while hospitals have for a long time been the foundation of America’s health care delivery system, care is now moving from the acute care arena and into the alternate inpatient settings, the community and the home, and in ambulatory settings; that is, hospital-centric towards community-centric care.
This shift means comprehensive primary care with a lot of emphasis given on wellness and disease prevention, as well as much better coordination across venues (Wilson, Whitaker & Whitford, 2012). Owing to this trend, it is predicted that â…“ of all hospitals would close by the year 2020 and only the most acutely ill, sickest patients would occupy hospitals beds in the future (Cardillo, 2013). As acute care beds continue to reduce, facilities that offer services like hospice, assisted living, rehabilitation, acute and sub-acute long-term care, and others are growing. As such, the role of the Registered Nurse in these settings is evolving and changing into one of a clinical consultant. More nurses are now becoming assisted living administrators and licensed nursing home administrators, and this puts them in a strategic position for bringing about the changes that need to occur (Cardillo, 2013). As a result, of the restructuring of America’s health care system, nursing roles will be reconceptualized. More nurses will become informaticians, care coordinators, health coaches, health team leaders, and primary care providers in various settings such as accountable care organizations and primary care medical homes (Cheung, 2011).
Continuity or continuum of care
Continuity of care is considered as an outcome of care as experienced by the patient or client during the care continuum. Care coordination and case management are some of the models or approaches used in achieving continuity of care (Cheung, 2011). Continuum of care helps in coordinating and offering personalized healthcare services without any disruption. Community health nurses have an integral role to play in maintaining continuity of care for both clients and patients as they transition to outpatients settings from inpatients settings. Community health nurses make use of technology in maintaining continuity of care, and they facilitate continuity or continuum of care via case management services. These services consist of focused supervision for personalized care, follow-up, as well as referrals to suitable resources (Wilson, Whitaker & Whitford, 2012). The creation of a continuing relationship between a health care provider and an individual, results in improved health outcomes. In essence, there are various emerging and current opportunities and roles for guiding and enhancing the journey of the client through care continuum. RNs have taken leadership roles such as telehealth nurses, case managers, and nurse navigators (Wilson, Whitaker & Whitford, 2012).
Accountable Care Organizations (ACO)
An ACO is understood as a network of hospitals and physicians who share the responsibility of offering care to patients under the new law. Groups of healthcare providers in ACOs work together as a team in coordinating care for a group of patients with the objectives of offering patient-centered, high-quality care, and decreasing costs (Cheung, 2011). Nursing staff members can play a major role in assisting ACOs with the delivery of high-quality care at reduced costs. The role of nurses would increase exponentially with the implementation of Accountable Care Organizations, as nursing staff members assume expanded roles like disease managers and care coordinators (Cheung, 2011). Given that Accountable Care Organizations would focus on improved care delivery and care coordination, nurses are better positioned to asses the current resources and levels of staffing, and identify ways of improving outcomes of patient. Many nurses are successfully transitioning into roles, which focus on expanded areas of expertise for example health and wellness, in addition to fiscal and business management (Wilson, Whitaker & Whitford, 2012).
Medical Homes
The patient-centered medical home is basically understood as a multi-disciplinary team approach to care within an office setting which considers the consumer/patient as a partner in that care. According to Wilson, Whitaker, and Whitford (2012), doctors employ social workers, RNs, APNs, various specialists, and therapists who make home visits to the clients mainly lead patient-centered medical homes. The Registered Nurse plays an important role on the team since she engages patients in their own care and coordinates that care. Cardillo (2013) pointed out that the National Nursing Centers Consortium is campaigning to have the national government to elect more APN-led clinics as patient-centered medical homes to officially authorize and recognize them, and increase reimbursement to them.
Nurse-managed health clinics
These are usually APN-led practices...