Core Competencies and the Continuum of Care

The high cost of health care has to be managed. This requires patients to learn about their own health conditions, and how to manage them appropriately so as to avoid setbacks and complications. Patients must take responsibility for their health status and practice wellness. In order to do this, patients have to be well educated about their medical status.

Across the continuum of health care, patient education begins in the physician’s office and carries through to the after hours care, the urgent care and emergency room, the hospitalists and the home health care team. Each professional and team builds on the education and assessment of the patient’s status and how to best assist him in attaining management of his health care status. Nurses are at the forefront of the process to ensure quality care across the continuum. Strong leadership skills and professionalism are essential for the success of this process.

Core Competencies
Roles for nurses are expanding rapidly to provide the necessary evidence-based education to patients so they can take control of their destinies. Nurses need to constantly improve their knowledge base and become the best patient educators they can be. Skills and competencies have to be top notch. It is no secret that lower patient mortality rates have long been linked to having BSN prepared nurses in charge of their care. Nurses who are best prepared to deliver health care also provide patients with the best possible options and outcomes. Advance practice nurses such as Clinical Nurse Specialists and  Nurse Practitioners have taken lead roles in driving the need for all nurses to obtain higher education. With the emphasis on wellness and not sick care now, this becomes essential.

Today’s nurses must have strong critical thinking skills and know how to actually practice nursing theories as well as employ the tools and core competencies they learned in school and have experienced on the job. They must utilize the continuum of care and understand their position in it with each patient. No one professional will see the process through from start to finish so it’s important for nurses to focus on the tasks at hand and provide the next level of care and then provide a thorough hand-off report for the education process to continue and patient outcomes maximized. Nurse educators in facilities are charged with the job of evaluating their staff’s skills and improving them through continuing education.

Avoiding Readmission Using Continuum of Care
Hospitals are charged with avoiding readmissions and this is best achieved through a strong continuum of care both in-house and with post acute care options. Teamwork and collaboration is vital as each team member builds on the previous information and reviews the patient’s understanding to plan for the next step. Quality patient-centered care and education includes hand-off reporting that ensures the wheel is not being reinvented from scratch with each subsequent patient encounter.

Home health care is proving to be a very effective choice after, or even in lieu of, acute care in providing quality patient education and achieving optimum outcomes. Hospital readmissions have been reduced, proving this continuum of care is effective. As this becomes more the norm, health care costs will be contained and patient outcomes improved.

Disclosure: This content has been brought to you by Halogen Software, the market leader in talent management software. Bringing value to nurses is at the forefront of Halogen Software’s goals so they are partnering with nurse leaders online to bring attention to important issues that healthcare organizations face every day. To find out more Halogen Software and the support they can provide to your nursing staff check out their healthcare page.

Further Resources:
Quality and Nursing: Moving from a Concept to a Core Competency