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Related Concept Videos

Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
Interdisciplinary Care: The Health Care Team-II01:18

Interdisciplinary Care: The Health Care Team-II

An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care. Here are a few more healthcare professionals.
Physical Therapist
A physical therapist (PT) aims to restore function or prevent additional impairment in a patient following an injury or disease. Massage, heat, cold, water, sonar waves, exercises, and electrical stimulation are some treatments used by PTs to treat...
Specialized Care Centers and Settings-II01:30

Specialized Care Centers and Settings-II

Rural Health Centers
Rural health centers are specialized care facilities in remote locations with very few medical personnel. The primary care providers who run the centers are mostly Registered Nurse Practitioners. Here, emergency treatment is provided to critically ill or injured patients before they are transferred to the closest hospital. Fortunately, due to advancement in technology, many rural healthcare facilities and professionals have easy access to diagnostic and treatment...
Community Based Intervention01:30

Community Based Intervention

Community-based interventions in mental health represent a paradigm shift from institution-centered care to treatments embedded within the fabric of local communities. By prioritizing inclusion and leveraging existing societal structures, this approach fosters a supportive environment conducive to addressing mental health challenges while promoting individual dignity and agency.
Foundations of Community Mental Health Programs
Central to the success of community-based interventions is the...
Interdisciplinary Care: The Health Care Team-I01:21

Interdisciplinary Care: The Health Care Team-I

An interdisciplinary team includes many healthcare professionals working together and utilizing their skills, knowledge, and expertise to provide holistic and quality patient care.
Physicians
The physician's primary responsibility is to diagnose illness and direct the medical or surgical treatment of the condition. The authority to admit patients to a healthcare agency or institution and practice care within that setting is granted to physicians by the healthcare agency or institution itself.

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Related Experiment Videos

Scaling up: bringing the transitional care model into the mainstream.

Mary D Naylor1, Julie A Sochalski

  • 1University of Pennsylvania School of Nursing, USA. naylor@nursing.upenn.edu

Issue Brief (Commonwealth Fund)
|November 9, 2010
PubMed
Summary

Effective care management for elderly, chronically ill patients, like the Transitional Care Model (TCM), reduces rehospitalizations and improves health. Translating these interventions into practice requires overcoming specific challenges.

Related Experiment Videos

Area of Science:

  • Gerontology
  • Health Services Research
  • Nursing

Background:

  • Elderly, chronically ill individuals face complex health transitions.
  • Frequent changes in health status necessitate care coordination across providers and settings.

Purpose of the Study:

  • Identify essential elements of care management interventions for this population.
  • Determine facilitators for translating the Transitional Care Model (TCM) into practice.

Main Methods:

  • Analysis of two projects focused on care management interventions.
  • Evaluation of the Translational Care Model (TCM) implementation.

Main Results:

  • The TCM, using in-person contact and a nurse-led interdisciplinary team, effectively reduces rehospitalizations.
  • Successful TCM translation improves patient health status and lowers healthcare costs.

Conclusions:

  • Care management innovations like TCM can interrupt rehospitalization cycles.
  • Overcoming challenges is crucial for widespread adoption of effective care management strategies.