Delivering Patient-and Family-Centered Care at Home

           The student will understand the core competencies of evidence-based practice, patient-and family-centered care, teamwork and collaboration with the construct of a care plan that is community focused. The student will follow the assigned holistic rubric to understand the parameters how a community-focused care plan will be designed while completing the Community Focused Practicum.  The BSN student will detail the patient assessment, what treatments are necessary for the diagnosis, along with using an interdisciplinary team to meet the outcomes by way of written case management plan.

            Patient-and family-centered care matters.  It matters that parents and other key caregivers are actively engaged as partnersin their child�s care and in every clinical encounter.  It matters that the patient and family voice is represented at both the organizational and policy levels, and evenincluded in the health system�s strategic planning process (Abraham &Moretz, 2012).

            According to the Institute for Patient- and Family-Centered Care: �Patient-and family-centered practitioners recognize the vital role that families playin ensuring the health and well-being of infants, children, adolescents, andfamily members of all ages.  They acknowledge that emotional, social, anddevelopmental supports are integral components of health care.  They promote the health and well-being of individuals and families and restore dignity and control to them (2015).�

            As homecare clinicians at Sutter Care at Home, we recognize that we never just treat our patient, but also our patient�s caregivers, families, and friends.   Our organization is committed to developing patient- and family-centered care by way of meeting their needs andassisting with constructing the patients and family �voice�.   The construct of care is designed to meet the patient�s physical care, the patients and families emotional care,planning short and long term goals, and revisiting the mentioned on a weekly or visit bases.  The recognition is proved in the outcomes of both the delivery of care by our clinicians but alsoin the pleasant responses of the patients and family as key team members in and interdisciplinary approach.  SutterHealth has coined this term in our mantra of �We Plus You�.  �What would we ever do without partners?  At Sutter Health, we partner with you toward a single goal: providing high-value, quality health care that�s morepersonalized and human.  It�s how we make health care better.  Most of all, it�s how we get better, together.  See how we�re putting partnership into action today (Sutter Health,2013).�

             Placing the reality, or �painting the picture� into the aforementioned, I, as apediatric oncology case manager, have had a front row seat to the construct of the patient- and family-centered care model.  Our agency meets weekly for a patient care conference (PCC).  This PCC consist of our agency director, supervisors, quality assurance nurse, educator, nurses, physical therapists,and our medical social workers.  We discuss each complex case in great detail and then develop plans of treatmentsto meet patient and families needs.  The following is a prime example of the construct to meetingpatient- and family-centered care.

Competencies and Outcomes

Competencies are imperative for educators to create course measures to assess and evaluate their students learned knowledge, validating experiences, and move the student successfully through their nursing career trajectory. Additionally, the mastering of competencies and core outcomes prove to both the student and the educator that learning expectations are met.  This Community Focused Care course has three important outcomes and competencies that will prove important as the student moves through the process of pre-licensure BSN to graduate nursing school.  Moreover, the makeup and the verbiage of the curriculatends to vary upon the descriptions of the catalog courses; course outcomes andcompetencies; course design and schedule of classes. From an ethical stance, and compelling into contemplation that this development is geared on tending to the needs of patient and community health needs, the course conclusions should incorporate patient-and family-centered care that is all-inclusive and congregation the requirements/needs of the total family as well as the patient.  The nurse understands this core competencyand meets goals within the community.  

Upon completion of this course, thenursing student will display essential understand of the followingcompetencies:  1) Patient-and Family-CenteredCare which is the method of placing the patient and their families in thecenter of care delivery; 2) Evidenced-based Practice is the integration of bestcurrent evidence with clinical expertise and patient/family preference andvalues for delivery of optimal health care; and 3) Teamwork and Collaboration by meeting with and creating a viable workingcase plan within the interdisciplinary team. Outcomes are measured by clearly demonstrating this importance whilecompleting a case study / role play model incorporating the aforementionedcompetencies.

 Model Case to Meeting Patient- and Family-Centered Care

              Alexia G. is a 15-year-old female with Leukemia in active treatment of 4 months into therapies.  Treatment consists of Ara-c chemo weekly at Lucile Packard Children�s Hospital (LPCH) in Palo Alto,CA.  Patient resides in rural Northern California and travels to and from LPCH weekly, often times spending nights at family center.  Alexia has moderate to severe nausea with vomiting, headaches, and anxiety 2-3 dayspost-chemo.  The nurse case manager (myself) makes home visits twice weekly to monitor her Nadir period and watch cell count recovery.  Collecting atrending report of her adverse symptoms; constructing a practice theory of how to prevent Alexia�s symptoms from causing a local hospitalization.  Moreover, developing a nurse-patientrelationship to begin meeting the patient and families needs. 

            The case manager (myself) meets with Alexia in private to begin to discuss how sheis feeling.  After a thorough assessment, the case manager collects the emotional issues that need to be met immediately and brings them for open discussion at our PCC.  For Alexia, the loss of her hair has put a deep strain on her desire to be socially active, including joining facebook.  Additionally, Alexia is fearful of the unknown aspects of her care,  (oftentimes, communication is directed towards the adults in regards to the trajectory of pediatric patient care) and wonders if she�ll ever be healthy enough to go back to school to be a normal teenager.  The case manager can then construct a viable plan to include Alexia into the decision making process, assist with wigs vs. hats, and encourage the teen to be social. Utilizing our MSW along with nursing staff for home visits and to assist in meeting our patient- and family-centered goals, we can ensure that Alexia�s care is tailored to fit her needs as an individual.  At final assessment, the case manager notes that Alexia is happy, wearing her wig, involved with her care in regards with discussing her own needs during rounding,and making a HIPPA appropriate facebook site where she can connect with her peers.  Lastly, Alexia states that she can now see herself free from cancer and going back to high school to join her friends.

References:

Abraham, M., & Moretz, J.G. (2012). Implementing patient- andfamily-centered care: part II- strategies and resources for success. PediatricNursing. 38(2), 106-109.

Institute of Patient- and Family-Centered Care (2015). Retrieved form:http://ods-security.com/healthcare/patient-and-family-centered-care/patient-and-family-care-centered-approach-to-security/

Sutter Health (2013), We Plus You: Partnership in Action. Retrievedfrom: http://www.sutterhealth.org/weplusyou/