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Introduction
It is necessary to mention that the role of innovative nursing care models has been increasing over the last few years, and it would be particularly reasonable to apply them in low-income countries. Chronic care is an area that has been chosen because the quality of such services in Nepal needs to be improved. High-quality treatment would help to limit the number of readmissions, and the generated funds can be used to purchase valuable equipment (Cowen & Moorhead, 2014). A nursing home was selected because the elderly in the region need help and support, and the approach would help to increase the number of positive outcomes.
Description of the Chronic Care Model
Information about various aspects of the proposed model will be provided in the discussion below. The most attention will be devoted to the influence and responsibilities of registered nurses (RNs).
Healthcare supervised by nurses
The model will be managed by several RNs that are experienced in this area. They will make some of the decisions related to the treatment and therapy if they are approved by physicians, and they will be based on evidence (Ackley & Ladwig, 2014). Moreover, RNs will participate in the discussions to determine if any alterations to the model are required. One of the most important aspects that should be highlighted is that it will be implemented by nurses.
The approach is reasonable because the central goal is to increase their involvement in management and it would help them to get a better understanding of operations within the facility. They will actively participate in the process of implementation and must promote the changes throughout the facility. An external professional will be hired, and he or she will help professionals to adjust to the changes. RNs will consult with specialists at first, but they should be able to make decisions regarding assessments, and communication when they gain experience. The budget will be discussed with the administration, and it is necessary to receive approval.
Collaboration and partnerships
Relationships with social workers will be critical in this case because the facility is planning to enhance the overall quality of life in the region. Such professionals will offer consultations and provide clients with all the necessary information regarding the nursing care model (Beaulieu, 2012). Dietitians will also be involved, and they would help to ensure that such problems as malnutrition and questionable eating habits are addressed. It is reasonable to collaborate with foreign agencies because the lack of high-quality food is an enormous problem. Community leaders will also have a vital role, and they will help with the provision of healthcare resources.
The importance of the partnership of the organizational level also should not be disregarded. It will be necessary to contact home healthcare organizations and discuss some of the aspects related to the quality of treatment and the importance of evidence-based practice. Overall, it is imperative to foster both internal and external collaborations in the future because it is an area that needs to be improved (Norlander, 2011).
Continuity of care
Cell phones will be used to deliver all the required information to the members of the family. Nurses will make calls or send messages every few weeks to discuss therapy. The Internet will also be utilized to ensure that the treatment is consistent after the client is moved to another setting. Professionals will discuss the approaches that must be used, and RNs will keep track of the process to make sure that complications are avoided. Patients and family members will be able to contact the facility and discuss some of the aspects related to therapy. Moreover, questionnaires will be utilized to identify which areas can be improved to enhance the overall experience of patients.
Technology
A healthcare facility has to deal with numerous resource shortages at the moment. Therefore, it will be possible to get access to high-tech if the nursing home is supported by external organizations. On the other hand, the proposed model is expected to be incredibly efficient and would help to minimize unnecessary expenses. Therefore, the required devices could be purchased in the future. This area can be viewed as rather problematic at the moment, but low-tech instruments that are available also have proven to be useful over the years. The most attention should be devoted to geriatric assessment tools because the ones currently used can be viewed as outdated and inefficient (Cress, 2012).
Most of them are incredibly cheap but will help to increase accuracy. It is necessary to translate the questionnaires developed in other regions to avoid possible inconveniences. Diagnostic tests also will be used, and several pieces of training will be conducted to identify any gaps in knowledge.
Implementation Team for the Chronic Care Model
The team will consist of RNs, certified nurse assistants, physicians, social workers, dietitians, and others. The number of professionals may be increased in the future if the model proves to be efficient. Most of the operations will be led by RNs, and their primary functions are to provide patients with high-quality healthcare, ensure that the funds are used effectively, and priorities are appropriate. Assistants will help with the process of treatment and will offer support to patients.
Dietitians will focus on the eating habits of clients and will try to ensure that nutrition levels are sufficient. Social workers must develop long-term relationships with the members of the community, and will increase the overall quality of healthcare delivery. Physicians will consult nurses and participate in the discussions regarding the treatment. The improvement of communication patterns in the facility is one of the primary goals. Nurse assistants will deliver all the necessary information to other professionals. Community workers may also help with referrals to ensure that nurses are not distracted and are focused on vital operations. Also, nurses will participate in research that would focus on diseases that are particularly problematic in the region (Hughes, 2006).
Evaluation of the Chronic Care Model
One of the most important indicators of the efficiency of the model is its cost and funds that can be saved after the implementation. It is necessary to keep track of these indicators every month to determine if the expenses were justified and it will be beneficial to the facility in the long-term. Available documents should be reviewed, and collected data must be put into spreadsheets for further analysis. It would be reasonable to utilize a survey to determine if satisfaction levels of both patients and healthcare professionals before and after the implementation have increased.
Both close-ended and open-ended questions should be used because the feedback received can be vital, and will help to get a better understanding of what adjustments are necessary. The number of readmissions is another indicator that is incredibly important, and the numbers should be compared every month to assess if the progress has been shown. In summary, frequent evaluations will help to avoid complications and minimize risks.
References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed.). St. Louis, MO: Elsevier Health Sciences.
Beaulieu, E. M. (2012). A guide for nursing home social workers (2nd ed.). New York, NY: Springer Publishing Company.
Cowen, P. S., & Moorhead, S. (2014). Current issues in nursing (8th ed.). St. Louis, MO: Elsevier Health Sciences.
Cress, C. (2012). Handbook of geriatric care management (3rd ed.). Burlington, MA: Jones & Bartlett Publishers.
Hughes, F. (2006). Nurses at the forefront of innovation. International Nursing Review, 53, 94-101.
Norlander, L. (Ed.). (2011). Transformational models of nursing across different care settings. Report: The future of nursing: Leading change, advancing health (Appendix G). Washington, DC: National Academy of Sciences, Institute of Medicine.
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