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Flashcards in Community & Home Health Deck (41)
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What is a community?

- Identified by a workplace, school, geographical area, medical need
- Group with a shared interest
- More than one person


Where is community-based care found?

Where people are


What is the definition of community-based nursing care?

Nursing care directed toward individuals of a specific group or population within the context of the community where they live


What are two examples of community-based nursing care?

- Clinics in schools
- Home healthcare


The local community health clinic identifies patients who have children in the a certain age range with asthma. This type of RN would review meds with the family, assure they know the s/s requiring medical attention, and participate in clinical case management review.

Community-based nurse


This type of RN would provide follow up with the family at the home visit. They would educate parents regarding preventative methods; assess for factors that might limit access to health care (ie no insurance); would refer to other needed resources (ie referral to environmental assessment). Info from the visit from would assist the RN in developing other resources (ie support group or written material that outlines ways to decrease common household allergies).

Community health nurse


This type of RN would monitor stats regarding ED visits for asthma. They would possibly identify that most children admitted to hospitals with complications secondary to asthma have little/no health insurance. A subsequent intervention would be for the public health nurse to advocate for the availability of low-cost healthcare for the at-risk children or to develop a program linking elementary schools with an asthma prevention program.

Public health nurse


Name some various roles for a community health nurse

- State health dept
- School nurse
- Occupational health nursing
- Hospice and home health nursing
- Community health clinics


What is hospice?

- Multidisciplinary team approach caring for terminally ill individuals (estimated to have less than 6 months to live). Can be home health or can be a facility.


What is focused on in hospice?

Focus on support and quality of life
• Physical, emotional, and spiritual


What does the RN focus on often?

Comfort. Treating pain or other undesired symptoms.


What do home health care services aim to maintain?

Maintain function, promote health, maintain ADLs! It's all about self care.


Home health is very interdisciplinary. What are some disciplines seen in this field?

- Social worker
- Case manager
- PT
- OT
- Speech therapy
- Home health aide


What is the function of a home health nurse?

Provides in-home assessment directs care, patient teaching and support, coordinates services, evaluates outcomes.


What is the function of a home health aide?

Provides hygiene care, cooking, supervision, companionship.


What is the function of a social worker in home health?

Are more prominent in community health but assists in finding and connecting with community resources or financial resources; provides counseling and support.


What is the function of a PT in home health?

Assists with restoring mobility, strengthens muscle groups, teaches ambulation.


What is the function of OT in home health?

Heals patients adjust to limitations by teaching new vocational skills and better ways to perform ADLs.


What is the function of a speech therapist in home health?

Teaches patients to communicate better and works with patients who have swallowing problems.


What is the function of a nutritionist in home health?

Teaches patients about meal planning and diet restrictions.


What is the function of a respiratory therapist in home health?

Provides home follow up for patients with respiratory problems including assessment, O2 administration, and home ventilator care.


What factors into the functional ability of patients in home health?

• Developmental stage
• Altered elimination
• Health promotion and safety
• Altered nutrition
• Cognitive and sensory deficits
• Decreased mobility

These are all things we would think of in a hospital but in a MUCH broader sense


What does a nurse need to function in community health?

Everything we are learning in Assessment class!
• Generalist background
• Knowledge of resources to connect patients with what they need


What are the phases of a home health nurse visit?

• Initiation
• Pre-visit
• In-home
• Termination
• Post-visit


What happens during the initiation phase of a home health nurse visit?

Find the purpose or reason you are going. Contact family. Find out if they even want you to come.


What happens during the pre-visit phase of a home health nurse visit?

Set up initial visit. Communicate purpose to family.


What happens during the in-home phase of a home health nurse visit?

Build rapport, set goals, nursing process.


What happens during the termination phase of a home health nurse visit?

Summarize visit, plan future visit.


What happens during the documentation phase of a home health nurse visit?

Documentation (go elsewhere to do this), plan for next visit.


What kind of information are you looking to collect about the home from your visit?

• Is anything in disrepair?
• Is there adequate food storage?
• Do they have access to all utilities?
• Is it clean, or is it able to be appropriately clean?
• Are there any infestation concerns?
• Is it safe?


Who advocates for safety issues?

The social worker. If not available, the RN.


What is it called when you compile all the info for different health care providers of your patient in on place?

Provider reconciliation


There is often a ____________ of services in home health care.



Who often makes the appointments for the patient in home health care?

The RN


What are the levels of discharge planning?

• Basic, universal
• Simple referral
• Complex referral


What is an example of basic, universal level of discharge care planning? Who is involved?

Self-care and illness teaching ie teaching about how to administer insulin.
People involved: Nurse, patient, caregiver


What is an example of simple referral level of discharge care planning? Who is involved?

Referring to community resources (ie support group referral).
People involved: Nurse, patient, caregiver


What is an example of complex referral level of discharge care planning? Who is involved?

Patient needs more specialized care after leaving the hospital.
People involved: Nurse, discharge planner, family


What is case management?

Coordination of care for patients that focuses on all areas of need


Who can be a case manager?

Nurse, social worker, Masters in Health Care Administration, respiratory therapist, other people on HC team.


_____________ focus takes into account patient ability to afford care, whereas ____________ focus is on
getting what is needed to promote optimal health. These can often make both disciplines are odds with each other.

Case management, home health nurse