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Foundations ch 9

Term Definition
advocacy protection and support of another’s rights
care coordination mechanism to make sure that patients get the right care at the right time in the most efficient and cost-effective manner, by the right person in the right setting.
care coordinator care provider (nurse case manager, social worker, community health worker, or lay person) who is responsible for identifying a person’s health goals and coordinating services and providers to meet those goals
care transition a continuous process in which a patient’s care shifts from being provided in one setting of care to another,
community-based care health care that is provided to people who live within a defined geographic region or who have common needs; designed to meet the needs of people as they move between and among health care settings
continuity of care coordination of services provided to patients before they enter a health care setting, during the time they are in the setting, and after they leave the setting
discharge planning systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care
handoffs a nurse’s report to another nurse or health care provider about a patient’s status and progress
home health care health care services provided in a patient’s home
ISBARQ revised approach to SBAR, adding introduction and question and answer components to SBAR
medication reconciliation form completed on admission checked and filled out again with each transfer and on discharge to ensure that all medications have been correctly ordered or discontinued as the patient moves through the system.
nurse navigator A clinically trained nurse responsible for the identifcation and removal o? barriers to timely and appropriate cancer treatment.
patient navigator This term includes all models o? navigation (nurse, social worker, lay person).
SBAR consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations.