MODALITIES OF CARE Modalities of care are ways care is organized and delivered to patients.

These models have been implemented to decrease expenses, to use staff more effectively and to provide high quality care efficiently and effectively. Models might also be called nursing or patient care delivery systems. A. Total Patient Care or Case Method Oldest mode of organizing patient care. The registered nurse is responsible for all of the care provided to a patient for a shift. It is sometimes referred to as the case method of assignment because patients were assigned as cases, much like contemporary private-duty nursing is carried out. At turn of 19th century, total patient care was generally provided in the patients home, and the nurse was responsible for cooking, house cleaning, and other activities specific to the patient and family, in addition to traditional nursing care. Rarely provided today, except among student nurses who are assigned to provide all of the case for a patient during the hours that they are in clinical. Even this case, the students frequently do not provide all of the care as they may not be qualified to do this.

Each nurse caring for the patient can, however, modify the care regimen. Therefore, if there are three shifts, the patient could receive three different approaches to care, often resulting in confusion of the patient. To maintain quality care, the method requires highly skilled personnel and thus may cost more than some other forms of patient care.

Advantages Provides nurses with high autonomy and responsibility. Assigning patients is simple and direct and does not require the planning that other methods of patient care delivery require. Lines of responsibility and accountability are clear. Patient theoretically receives holistic and unfragmented care during the nurses time on duty. Disadvantages Lack of consistency and coordinated care when care is provided in 8 hour segments. When the nurse is inadequately prepared to provide total care to the patient. B. Functional Nursing

Evolved during World War II as a result of a nursing shortage task oriented Best system when there are many patients and professional nurses are few short-term use only The advantages of functional nursing are: A very efficient way to deliver care. Could accomplish a lot of tasks in a small amount of time Staff members do only what they are capable of doing Least costly as fewer RNs are required Tasks are completed quickly .Workers gain skill faster in a particular The disadvantages are:

Care of patients become fragmented Patients do not have one identifiable nurse Very narrow scope of practice for RNs Leads to patient and nurse dissatisfaction Evaluation of nursing care is poor and outcomes are rarely documented C. Team Nursing Team nursing was developed in the 1950s in an effort to decrease the problems associated with the functional organization of patient care. Many believed, despite a

continued shortage of professional nursing staff, a patient care system had to be developed that reduced the fragmented care that accompanied functional nursing. In team nursing, ancillary personnel collaborate in providing care to a group of patients under the direction of a professional nurse. As the team leader, the nurse is responsible for knowing the condition and needs of all patients assigned to the team and for planning individual care. The team leaders duties vary depending on the patients needs and workload. These duties may include assisting team members, giving direct personal care to patients, teaching, and coordinating patient activities. Through extensive team communication, comprehensive care can be provided for patients despite a relatively high proportion of ancillary staff. This communication occurs informally between the team leader and the individual team members and formally through regular team planning conferences. A team should consist of not more than five people or it will revert to more functional lines of organization. Team nursing is usually associated with democratic leadership. Group members are given as much autonomy as possible when performing tasks, although responsibility and accountability are shared by the team collectively. The need for excellent communication and coordination skills makes implementing team nursing organization difficult and requires great self-discipline on the part of team members. Team nursing allows members to contribute their own special expertise or skills. Team leaders, then, should use their knowledge about each members abilities when making patient assignments. Recognizing the individual worth of all employees and giving team members autonomy result in high job satisfaction. Disadvantages to team nursing are associated primarily with improper implementation rather than with the philosophy itself. Frequently, insufficient time is allowed for team care planning and communication. This can lead to blurred lines of responsibility, errors, and fragmented patient care. Joel (1994) states that, although there is a demonstrated need for assistive personnel, such personnel should never be assigned to the patient but must always be assigned t the nurse. For team nursing to be effective, the leader must have good communication, organizational, management and leadership skills and must be an excellent practitioner.

D.

Primary Nursing Also known as relationship-based nursing It is a one-to-one relationship between the Registered Nurse and the patient It requires a nursing staff made up only of RN This structure lend itself well to home health nursing, hospice nursing and other health care delivery enterprises

Primary Nurse Is a registered nurse assumes a 24-hours responsibility for planning the care of one or more patients From admission to discharge During working hours: provides total direct care to the patient Must be knowledgeable and must have high level of clinical autonomy Establish communication among the patient, physician, associate nurses and other health team members

Associate Nurse Takes care o the patient when primary nurse is not on duty Follows the care plan established by the primary nurse

Primary Nursing: Advantages Holistic, high-quality patient care is achieved through a combination of clear, interdisciplinary group communication, and consistent, direct patient care Job satisfaction is high Nurses feel challenged and rewarded

Primary Nursing: Disadvantages Job satisfaction is high but difficult to implement because of the degree of responsibility and autonomy required Improper implementation: Inadequately prepared, incompetent and lack experience nurses

E. Care and Service Team Models 1980, care and service team models began to replace primary nursing. Key elements: empowered staff, interdisciplinary collaboration, skilled workers, and a case management. Care and service teams introduced the different categories of assistive personnel. Complementary models o Begun in 1988 by using nursing extenders, such as a unit assistant, who would be responsible for environmental functions. Substitution models o Tend to use multiskilled technicians to perform select nursing activities. Cross-training o It is another more prevalent approach today o This involves training staff to work in different specialty areas to perform different task. Case management

o o

Can be viewed as a nursing model when the case managers is a nurse The focus of the team is on patient-centered care as opposed to the nursepatient relationship.

F. Care Management Model Goal: To integrate a continuum of clinical services Description: Focuses on the needs of the integrated delivery system Includes planning, assessment, and coordination of health services Not only concerned with medical care but also health promotion and disease prevention, costs, and use of resources instead of based on individual patient Population may be: the entire population members of a managed care plan Specific group with similarities (e.g. patients with diabetes) TYPICAL TOOLS used to facilitate care management Disease Management Programs Clinical Pathways Benchmarking Disease Management Programs help guide the care of patients with chronic health problems appear to improve the quality of health care. Clinical Pathways standardized, evidence-based, multidisciplinary management plans, which identify an appropriate sequence of clinical interventions, time frames, milestones and expected outcomes for an homogenous patient group. BENCHMARKING

It is a systematic approach and has been described as the "search for the best practices that will lead to superior performance" (Camp, 1989). involves comparisons between practices that have been achieved. G. THE INTERDISCIPLINARY TEAMWORK SYSTEM MODEL: The Interdisciplinary Teamwork System described by Drinka (2000) provides further development of the concept of collaborative team practice. It utilizes several identified methods of team practice in a "fluid system" that changes to match the health care problem with the most appropriate practice method. In this teamwork system the universe of health care professionals and health carerelated professionals and non-professionals is large. Drinka defines the Interdisciplinary Health Care Team (IHCT) as "a group of individuals with diverse training and backgrounds who work together as an identified unit or system. Team members consistently collaborate to solve patient problems that are too complex to be solved by one discipline or many disciplines in sequence. In order to provide care as efficiently as possible, an IHCT creates "formal" and "informal" structures that encourage collaborative problem solving. Team members determine the teams mission and common goals: work interdependently to define and treat patient problems; and learn to accept and capitalize on disciplinary differences, differential power and overlapping roles. To accomplish these they share leadership that is appropriate to the presenting problem and promote the use of differences for confrontation and collaboration." For an Interdisciplinary Health Care Team to function well, it must have the capacity to adapt to changing and complex situations. Methods of Interdisciplinary Health Care Practice: Six methods of team practice are outlined that can function as a system for providing efficient health care when understood and utilized appropriately. Leadership and Decision-Making: There are several approaches to the leadership of an interdisciplinary collaborative team. Historically, physicians have had the role of team leader in health care settings due to various cultural, gender, and power factors. Still relevant today remains the issue of legal responsibility for patient care. An emerging pattern in many primary care teams, however, involves equal participation and responsibility on the part of team members with "shifting" leadership determined by the nature of the problem to be solved. Emphasis by the team on "health care" rather than the more narrow focus of "medical care" broadens the roles and responsibilities on nonphysician providers.

Description

Advantages

Disadvantages Solutions lack depth/breadth Some fear expressing views Status may hinder

Ad Hoc/Task Group

1 Focus on one issue discipline/department/agenc y No elaborate rules Group selects or agrees on a Quick and dirty leader

Rules set by the group Solves a problem and disbands One discipline/department 1 agency Members report to group Individual identities more important than integrated diagnoses

Members capture enthusiasm

openness Difficulty getting together

Members speak same language Final decisions by formal leader Ongoing Rules established to keep order Security of one discipline Solutions may have depth

Some resent leaders decisions Solutions lack breadth May miss important problems Little integrative dialogue Inefficient with complexity Some resent leaders decisions

FormalUnidisciplinaryWork Group

(e.g., MDs from multiple specialties Dont work on team problems Leadership by election or rank Discipline specific care 1 discipline/department/ 1 agency Members report to group Individual identities more important than integrated diagnoses Dont work on team problems Leadership by election or rank Discipline specific care

Final decisions by formal leader Ongoing Rules established to keep order Information from many perspectives Solutions may have breadth

Speak different languages Solutions not integrated Different cultures of disciplines not used advantageously Little integrative dialogue Inefficient with complexity Initial decisions take more time Solutions may lack breadth May miss important problems

Formal Multidisciplinary Work Group (e.g., MD, RN, SW, OT)

One discipline/department/ 1 Members speak same agency language InteractiveUnidisciplinaryTea m (e.g., MDs from multiple specialties) Integrated diagnoses Team goals for patient and team Members interdependent Share responsibility for leadership More openness More informal collaboration

Team structures enable collaboration Work on team problems Leadership appropriate to issue/ expertise 1 discipline/department/ 1 agency Integrated diagnoses Team goals for patient and team Members interdependent Team structures enable collaboration Work on team problems Leadership appropriate to issue/ expertise Individual decides based on knowledge

Solutions have depth Members feel empowered Culture encourages creativity Integrated care Share responsibility for leadership Solutions address complex problems Solutions have depth & breadth Members feel empowered Creative approaches to complexity Understand autonomous practice

Need time and space to discuss values; renegotiate roles, leadership, conflict

Initial decisions take more time Members must learn different languages/terms Effort to maintain the team Need time and space to clarify values; renegotiate roles, leadership, conflict

Interactive Interdisciplinary Team (e.g., MD, RN, SW, OT)

Autonomous Practice

Works only if understands Quick, appropriate solutions interdisciplinary practice