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UNIT : NURSING LEADERSHIP AND MANAGEMENT: Patient Care Delivery System

1.0 Intended Learning Outcomes

1. Explain the Concept of Patient Care Delivery System.

2. Discuss the topics concerning Patient Care Delivery System such as Nursing Process in the
Delivery of Nursing Care Services; Patient Classification System and Modalities of Care
3. Formulate a plan of care to address the health conditions, needs, problems, and issues based
on priorities of the patient.
4. Develop a health education program using selected planning models to targeted clientele.

1.1. Introduction

Staying healthy is an important part of everyone's life, since good health determines how productive
a person can be and how much they can participate in daily activities. People with good health are
free from disease, and their bodies function efficiently. People need guidance in how to stay healthy.
Scientists and medical professionals conduct research and develop guidelines to help people manage
their health. A health care delivery system is an organization that provides resources and treatments
that help people when they are sick or injured, and helps them stay healthy through preventive care.
A health care delivery system definition includes all the institutions, organizations, people and
resources that help a particular group of people stay healthy.
The World Health Organization (WHO) is an international organization assembled by the United
Nations (UN) in 1948. The UN is a group of 193 countries, organized in 1945, that work together to
support international peace, justice, respect, human rights, and tolerance. The WHO was organized to
promote cooperation in providing health care internationally. The WHO compiles data on health care
and outcomes on a global basis. A good example of how the WHO tries to coordinate world health
was seen at the beginning of the Covid-19 pandemic in late 2019. The WHO compiled global
information about care provided to people with Covid-19 and the outcomes of that care. The global
data allowed the WHO to provide ''best practices'' information and guidance. The WHO has to
consider and advise countries based on the resources available to the specific country. The WHO
provides indirect patient care, because they provide guidance and information that health care
delivery systems use to develop the guidelines and procedures for direct patient care. Since the
WHO primarily provides health care guidance, and not direct health care services, they do not have
the power to require countries to provide health care to their populations.
Every country has a unique healthcare delivery system, with different resources available to provide
healthcare to its population. Delivering health care in America is challenging compared to some
countries because the US health care delivery system is somewhat unique because it does not have
one single organization that provides health care to its population. When a single organization delivers
health care it's called universal health coverage (UHC). This is common in countries besides the
US.
The World Health Organization (WHO), an agency of the UN (United Nations), focuses on
international health. WHO has defined a health system, also called a health care delivery system,
as ''all the activities... to promote, restore, or maintain health.'' This broad definition includes policies,
regulations, laws, and both direct and indirect patient care.

Most industrialized countries other than the United States provide a system of Universal Health Care
coverage for their residents. Universal health coverage, commonly known as universal health care
(UHC), is defined by WHO as a method to ensure that all people obtain the health services they need
without suffering financial hardship when paying for them. According to WHO, health care systems'
goals are:
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• Good health for the citizens

• Responsiveness to the expectations of the population
• Fair means of funding operations

On the other hand, the Department of Health defined Public Health Care Provider Network
(HCPN) as a type of HCPN that is owned and managed by the public sector. It is created by linking
a group or cluster of public primary care providers and facilities with secondary and/ or tertiary care
providers within defined geographic or political boundaries. The Public HCPN has two (2) sub-types,
the Province-Wide Health System (PWHS) and City-Wide Health System (CWHS).

• The Province-Wide Health System (PWHS) consists of the provincial, municipal, and
component city health offices; provincial, district, and municipal hospitals; health
centers; barangay health stations; and other LGU-managed health facilities and
services.
• The City-Wide Health System (CWHS) includes the city health office, hospitals,
health centers, barangay health stations, and other city-managed health facilities and
services in highly urbanized cities (HUCs) and independent components cities (ICCs).

The organization of the P/CWHS shall be first implemented in LGUs that expressed their
commitment, otherwise known as the Universal Health Care Integration Sites (UHC IS), to determine
the impact of an integrated local health system in improving overall health outcomes and to have
readily available models that the rest of the LGUs can use as a guide to organizing their P/CWHS
when nationwide roll-out is implemented. The status of each UHC IS in progressively realizing the
integration reform will be tracked using the Local Health Systems Maturity Levels (LHS ML). The
LHS ML outlines the ten (10) key integration characteristics, one of which is the Unified System of
Governance of the Local Health Systems.

MAIN TOPIC

A Nursing Care Delivery System defines the way we use our nursing values to care for our patients,
families, colleagues, and selves.

The care delivery system is actually a subsystem of the professional practice model that describes our
approach to delivering patient care:

1. Detailing assignments, responsibilities, and authority to accomplish patient care;

2. Determining who is going to perform what tasks, who is responsible, and who makes decisions;
and
3. Matching the number and type of caregivers to patient care needs.

Healthcare delivery systems can be divided into 4 major components or functions:

• Services: Healthcare assistance is available.

• Consumers: People in need of health care, both preventive and curative.
• Personnel (providers): People who provide health care. This includes doctors, nurses,
physical therapists, nursing assistants, hospitals, nursing homes, medical equipment suppliers,
and any other healthcare provider.
• Payment: Method of paying for health care services. Healthcare can be expensive, so
arranging for payment is a very important piece of any healthcare delivery system.
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o Financing: How to pay for the services is an important part of any health care delivery
system. Methods of payment include patient self-payment, payment provided by a
single governmental agency (known as universal health coverage), or insurance
companies. Insurance can be purchased by individuals, or by companies on behalf of
their employees.
o Delivery: Personnel providing services need to be paid.
o Insurance: A method of paying in advance for possible health care needed. In the US,
a person, known as a subscriber, pays a regular monthly premium to an insurance
company. In exchange, the insurance company will pay for health care on the
subscriber's behalf. There are also programs that are run by the government and paid
for with taxpayer money.
o Payment: Personnel is needed to process payments on behalf of the payor (who is
paying for the health care) and on behalf of the payee (organization receiving health
care payments).

A. NURSING PROCESS IN THE DELIVERY OF NURSING CARE SERVICES

Since the time of Florence Nightingale, the continuity of nursing care has been indispensible and, as
of the 1950s, the care plan has been considered the ideal solution for the care of critically ill patients.1
Nursing, realizing the need to develop a working method that would make its practice more visible,
legitimate and autonomous, sought its identity by developing its own body of knowledge.

The “Nursing Process” then emerged, which was used for the first time in 1961 by Orlando. The
Nursing Process (NP) at that time consisted of three basic elements: the client’s behavior, the nurse’s
reaction, and the nursing actions. Care was planned based on these components and was then carried
out in phases. In 1985, the World Health Organization officially proposed its four-phase
operationalization: Assessment, Planning, Implementation, and Evaluation.

On the other hand, Stonehouse, DP (2017) had an article stating that historically the medical model
was used, whereby a diagnosis was made by a doctor, and care was prescribed based on physical
symptoms alone (Hamilton and Price, 2013). This ignored the holistic needs of the patient. To develop
more of a problem-solving focus in nursing care (Melin-Johansson et al, 2017) the nursing process
was proposed by Yura and Walsh in 1967. It is seen as a “decision-making approach that promotes
critical thinking” (Yildirim and Ozkahraman, 2011:261). It comprises a cyclical process of four stages
which are known as assessment, planning, implementation, and evaluation. A fifth stage has
subsequently been added coming immediately after an assessment, namely nursing diagnosis
(American Nurses Association, 2017).

Even though the initial assessment and planning will often be performed by a nurse, the support
worker will be involved in all aspects. They will often be the person who then implements the planned
care and evaluates its appropriateness and success as care is delivered. Ongoing assessment takes
place and the support worker will be closely involved in this. A more accurate name for the nursing
process today could be the Caring Process which would incorporate all members of the
multidisciplinary team involved in the care of the patient.

Assessment

This is the first stage of the nursing process. It involves the collection of information from the patient
and their family/carers concerning their condition and perceived problems. Hamilton and Price (2013)
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state that this is the cornerstone in establishing the needs of the patient and if done well, the nursing
process will be a success. Information can be collected in a number of ways and the support worker
will take an active part in this. Good communication, both verbal and non-verbal, together with
observational skills are key.

Even before the nurse or support worker has seen the patient there will often be existing notes to read
or a handover to receive. This initial information will help to guide the first stages and should give
the nurse a starting point on how to approach the patient. Identifying any communication needs and
recognizing if any special adjustments need to be made. Of course in certain situations, this is not
always possible, where a patient is admitted urgently to the accident and emergency department and
care must commence immediately, an initial short-term assessment will be made (Hamilton and Price,
2013).

The next part of the assessment takes place even before any words are spoken. As you approach the
patient you will be observing them and looking for any outward signs, both positive and negative.
This can be done very quickly on first seeing the patient. Do they look in pain, do they appear to be
pale or clammy? Are they conscious and sitting up, or appear unconscious?

An assessment of the patient’s airway, breathing, and circulation needs to be performed immediately.
Once these three areas have been assessed as being stable, then a more formal assessment can take
place. Observations are taken to gain a baseline and again to identify anything abnormal which may
need urgent intervention. Pulse, respirations, blood pressure, oxygen saturations, capillary refill time,
and anything else which is relevant to the patient presenting problems. These are all recorded to be
repeated and compared.

The focus of the assessment is the patient and how they are experiencing their illness and ill health.
Once all the information has been collected it can be documented and sorted (Melin-Johansson et al,
2017). Excellent record-keeping is key so that all the information gathered is recorded and presented
in a way that is accessible to the whole multidisciplinary team.

Nursing Diagnosis

This is an extra stage to the original four and is more wide spread and common in North America.
Here the information gained from the assessment is used to identify actual and potential problems, as
well as strengths (Yildirim and Ozkahraman, 2011). Strengths might be self-caring abilities or
independence in certain areas. Or prior knowledge or experience of the illness. Actual problems are
those that come directly out of the assessment, for example pain from a fracture. Potential problems
are those that could arise from out of the problem, for example the risk of developing a pressure sore
if confined to bed (Hogston, 2011). However Peate (2013) has a word of warning that the person
making the diagnosis must have gained the sufficient expertise and experience to do so, otherwise this
could be potentially dangerous.

Planning

The planning stage is where interventions are identified to reduce, resolve or prevent the patient’s
problems while supporting the patient’s strengths in an organized goal-directed way (Kozier et al,
2008). Care needs to be prioritised on the needs of the patient and the seriousness of the problems
identified. Hogston (2011) identifies two steps in the planning stage, setting goals and identifying
actions. Goals need to be set, both short-term and long-term. SMART goals should be identified which
are Specific, Measurable, Achievable, Realistic, and Timely (Hamilton and Price, 2013). These are
all done in collaboration with the patient.
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In action planning the actual care that is going to be implemented needs to be clearly stated. Hogston
(2011) advises using the REEPIG criteria to ensure that care is of the highest standards. Firstly, the
care planned is Realistic given available resources. Secondly, the care planned is Explicitly stated. Be
clear about exactly what needs to be done so there is no room for misinterpretation of instructions.
Thirdly, Evidence-based. That there is research that supports what is being proposed. Fourthly, the
care being planned is Prioritized. The most urgent problems are being dealt with first. Fifth is to
Involve both the patient and other members of the multidisciplinary team who are going to be involved
in implementing the care. And lastly, Goal centered, that the care planned will meet and achieve the
goal set.

Implementation

This is where the care is delivered and more than likely it will be the support worker who will be
delivering the majority of the basic and increasingly, more advanced care. Especially when the patient
is in their own home or a community setting. Implementation of the care occurs throughout the twenty-
four-hour period. As each new member of the caring team comes on duty they need to re-assess if the
care being delivered is still appropriate. Has anything new been developed to change the plan of care?
How is the patient responding to the care delivered? Ongoing assessment of the patient is vital and
again this is where good record-keeping is important (Alfaro-LeFevre, 2010).

Evaluation

The most important part of the nursing process after the assessment is done is evaluating has the care
achieved the desired result. This should not just occur at the end of a course of treatment or care but
should occur constantly as care is being implemented. Evaluation at the end of a course of treatment
involves a reassessment of all the plans of care to determine if the expected outcomes have been
achieved (Yildirim and Ozkahraman, 2011). Hogston (2011:16) also states that evaluation is an
“opportunity to review the entire process and determine whether the assessment was accurate and
complete, the diagnosis correct, the goals realistic and achievable, and the prescribed actions
appropriate.” With evaluation, the whole process starts again.

Furthermore, Mjc.edu (2012) published an article stating that the common thread uniting different
types of nurses who work in varied areas is the nursing process—the essential core of practice for the
registered nurse to deliver holistic, patient-focused care. One definition of the nursing process...” an
assertive, problem-solving approach to the identification and treatment of patient problems. It
provides an organizing framework for the practice of nursing and the knowledge, judgments, and
actions that nurses bring to patient care.”

Assessment

An RN uses a systematic, dynamic, rather than a static way to collect and analyze data about a client,
the first step in delivering nursing care. Assessment includes not only physiological data, but also
psychological, sociocultural, spiritual, economic, and lifestyle factors as well. For example, a nurse’s
assessment of a hospitalized patient in pain includes not only the physical causes and manifestations
of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from
family members, anger directed at hospital staff, fear, or request for more pain medication.
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Diagnosis

The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential
health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain
has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the
potential to cause complications—for example; respiratory infection is a potential hazard to an
immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Planning / Goal / Outcome

Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-
range goals for this patient that might include moving from bed to chair at least three times per day;
maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through
counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals
are written in the patient’s care plan so that nurses as well as other health professionals caring for the
patient have access to it.

Implementation

Nursing care is implemented according to the care plan, so continuity of care for the patient during
hospitalization and in preparation for discharge needs to be assured. Care is documented in the
patient’s record.

Evaluation

Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and
the care plan modified as needed.

Issues

To perform a good assessment of a patient takes time and time must be devoted to this crucial
cornerstone. Otherwise, the following stages will not have the information required to deliver quality
care. In a study by Abdelkader and Othman (2017:81) it was found that “lack of knowledge, high
patient-nurse ratio/workload, and lack of educating, training and motivating factors affected the
application of the nursing process.” These factors need to be recognized by managers and individual
staff so that sufficient time is devoted to it and knowledge and awareness are raised to the important
part this caring process plays in delivering high-quality care.
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B. PATIENT CLASSIFICATION SYSTEM

Providing the right care for each individual patient is a key element of quality palliative care.
Complexity is a relatively new concept, defined as the nature of patients’ situations and the extent of
resulting needs. Classifying patients according to the complexity of their care needs can guide the
integration of services, anticipatory discussions, health service planning, resource management, and
determination of needs for specialist or general palliative care. However, there is no consistent
approach to interpreting and classifying the complexity of patient needs. (Grant et al, 2021)

The first studies on PCS appeared more than 40 years ago and, since then, the instruments have been
improved, and their use in nursing practice has been consolidated. By revealing patients’ needs in
relation to nursing care, this tool has helped in workload management, in order to balance available
resources and clinical demands, and also support workforce planning, even referred to as the basic
element in this process. (Cucolo et al, 2022)

The Patient classification system (PCS), also known as the patient acuity system, is a tool used for
managing and planning the allocation of nursing staff in accordance with the nursing care
needs. Thus, PCS is used to assist nurse leaders to determine workload requirements and staffing
needs.

There are different kinds of PCS available, but the three most commonly used are:

Descriptive - This is a purely subjective system wherein the nurse selects which category the
patient is best suited.
Checklist - Another subjective system, wherein the patient is assigned a numerical value
based on the level of activity in specific categories. The numerical value is added up to give the nurse
an overall rating.
Time Standards – This is another method where the nurse assigns a time value based on the
various activities needed to be completed for the patient. This time value is summed up and converted
to an acuity level.

Among these three, the most commonly used is the descriptive kind of Patient Classification
System. These are subdivided into four classifications namely:

Self-care / Minimal Care. The first classification of patients who are recovering and
normally require only diagnostic studies, minimal therapy, less frequent observations, and daily care
for minor conditions and are awaiting elective surgery.
Moderate care. The patient in this category is moderately ill or in the recovery stage from a
serious illness or operation. They require nursing supervision or assistance that is related to
ambulating and caring for their own hygiene.
Maximum care. The patient needs close attention and complete care all through the shift.
The nurses initiate, supervise, and perform most of the patient's activities.
Intensive care. The last category or classification, wherein the patients are acutely ill and a
high level of nurse dependency is required. Intensive therapy and/or intensive nursing care are needed
because of the unstable condition of the patient. Frequent evaluation, observation, monitoring, and
adjustment of therapy are also required. Patients in these levels include those in critical conditions or
in life-and-death situations.
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But whatever PCS is used, this will be applied to forecast staffing needs within each department.
Nurses should be informed of the patient care ratios that are relevant to each department and should
understand how to predict staffing needs.

Moreover, Grant et al (2021) express their idea that there is a Classification Systems or Case-Mix
classifications that are designed to systematically determine the level of patient care needs; thus,
classifying patients according to their complexity. Such systems have been employed in acute
medicine to determine patients’ resource usage and care needs, based primarily based upon diagnoses,
but have been shown to not reflect care requirements in palliative care services. It is unclear what
classification systems have been developed or applied to populations with palliative care needs, which
aspects of complexity they address, and their effect on clinical care. Given that complexity is a
relatively new concept in palliative care, it is possible that there are classification systems that may
pre-date the use of this terminology. The systematic classification of patients according to the
complexity of their care needs may provide important insights into the situational needs of patients;
to determine care pathways, identify those who may benefit from additional care input, assist health
services in resource management, and proactively engage with patients about their future care needs.
Appreciating how complexity is understood and operationalized in different settings (i.e. home,
hospice) may enable palliative care services to consider schemas relevant to their specific needs and
populations.

Final Considerations

The development of instruments capable of identifying nursing care needs is undoubtedly a landmark
worthy of consideration by the profession, which deserves due recognition. Known as PCS, such
instruments are fundamental in workforce planning and sizing, constituting, therefore, an
indispensable tool in NWL rationalization, especially in hospitals.

On the other hand, the evolution of activities and the complexity of the nursing practice environment
have shown that the PCS are not sensitive to the completeness of the workload that professionals
routinely face. This means that there are both objective and subjective nuances of this “variable” that
go beyond verification mediated by a scale/instrument, even if it is highly qualified and duly validated.

C. MODALITIES OF CARE

In the last century, numerous nursing modalities – also called nursing care models – emerged to meet
the ever-changing needs of patients and the healthcare industry. Each nursing professional plays a
critical role in patient care and the way in which patients experience their health care. Nursing care
models vary in administration and scope. While some provide quality care for large numbers of
patients, others focus on serving the needs of individuals. Nursing care models are fluid, allowing
each hospital, clinic, or private practice to devise a method to serve patients.

Functional Nursing Model (Task-Oriented)

The functional nursing method is a decades-old, traditional form of patient care. The model relies on
a hierarchy of nurses who perform different tasks depending on their level of education, training, and
experience.

The team leader, a registered nurse (RN), collaborates with physicians to determine the needs of a
patient. The head nurse then delegates tasks to nurses under her supervision. For example, she might
assign another registered nurse to administer treatments, while a licensed practical nurse (LPN)
monitors blood pressure and a nurse's aide assists the patient with an exercise regime.
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Functional nursing applies an assembly-line method of patient care, which can offer economic
advantages for the hospital because it maximizes each team member’s skill set. This nursing model
works well in periods of high demand, such as wartime or during epidemics. However, functional
nursing does not provide the holistic care that many patients need, because the nurses focus on their
individual tasks rather than the overall condition or progress of the patient.

On the other hand, Parreira et al (2021) presented a table showing the structure of the functional
nursing method. He emphasized that Functional nursing, also known as task nursing, focuses on the
distribution of work based on the performance of tasks and procedures, where the target of the action
is not the patient but rather the task. The work is thus broken down into tasks performed by different
professionals, from a mechanistic perspective. The adoption of this method in care organization is
based on Taylor’s principles of the industrial revolution, promoting the maximization of the task in a
routine and mechanistic logic. As shown in Figure 3, this care delivery model is characterized by a
lack of coordination between the parts, represented by “piecemeal” interventions in task-oriented care
delivery, of an interrelated whole (non-holistic care to the patient). However, a significant number of
health managers and administrators believe that “functional” nursing is an economically efficient care
delivery method.
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Advantages:

§ 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
Disadvantages:

§ Care of patients becomes fragmented and depersonalized

§ Patients do not have one identifiable nurse
§ The very narrow scope of practice for RNs
§ This leads to patient and nurse dissatisfaction

Team Nursing Model/Modular Nursing

Developed in the 1950s, the team nursing model is similar to the functional nursing method but
provides care on a larger scale. The team nursing model assigns an RN as the group leader who
delegates tasks to a team of medical professionals who care for multiple patients.

Teams contain at least two nurses, typically with different experience, education, and skill levels. An
RN team member might dispense medications, while an LPN monitors the patient blood pressure. The
team might also include a nurse’s aide, who carries out tasks such as bathing and dressing the same
group of patients.

Surveys of nurses have yielded high marks for the team nursing model. Inexperienced nurses
appreciate the opportunity to work with and learn from their experienced colleagues. Likewise,
experienced nurses report that they feel more supported in their duties under a team nursing model.
The team nursing approach also benefits medical facilities by enabling inexperienced nurses to learn
more quickly, giving them increased value as employee assets. The method also promotes and
improves communication among team members, which can result in improved patient care.

Team nursing relies on team leader RNs with good management and leadership skills. Patient needs
can impact the success of the team nursing method. Designed to provide care for numerous patients,
the team nursing model does not offer appropriate coverage for patients who need constant care and
attention.

Advantages:

§ Each member’s capabilities are maximized so job satisfaction should be high

§ Patients have one nurse (the Team Leader) with immediate access to other health providers
Disadvantages:

§ Requires a team spirit and commitment to succeed

§ RN may be the Team Leader one day and a team member the next, thus continuity of patient care
may suffer
§ Care is still fragmented with only 8 or 12 hour accountability
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Primary Nursing Model

The primary nursing model assigns patients to a primary RN, who takes responsibility for their care
throughout the hospital stay. By following a patient’s progress, the RN can provide a more holistic
level of care, while offering the patient the comfort of having a primary caregiver among the nursing
staff.

The primary nursing method developed in the 1970s and quickly gained popularity. It addressed the
shortcomings of older models such as functional and team nursing, which left gaps in patient care
because of task-oriented approaches. Primary nursing has proven particularly successful in meeting
the needs of patients with complex medical conditions. For example, a patient with diabetes might
have heart problems, tissue damage, and dietary restrictions, which require the type of comprehensive
care a primary nurse can provide. Patients respond well to the primary nursing model because it
provides them with knowledgeable medical contact and a sense of continuous care. Generally, nurses
appreciate the feeling of autonomy primary nursing offers, while enabling them to provide patients
with a high level of care.
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Flexible work schedules, which allow nurses to work three consecutive days of 12-hour shifts,
followed by four days off, create a disadvantage to the primary nursing model, particularly for patients
who require long-term hospital stays.

The primary nursing model has remained relatively unchanged since its conception. Most studies
indicate that it provides a higher level of job satisfaction for nurses and is popular among patients.
However, results have largely offered anecdotal evidence and lack hard data about how primary
nursing’s quality of care compares with models such as team and functional nursing.

Advantages:

§ Increased satisfaction for patients and nurses

§ More professional system: RN plans and communicates with all healthcare members. RNs are
seen as more knowledgeable and responsible.
§ RNs more satisfied because they continue to learn as as part of the in-depth care they are required
to deliver to their patient
Disadvantage:

§ Only confines a nurse’s talents to a limited number of patients, so other patients cannot benefit if
the RN is competitive
§ Can be intimidating for RNs who are less skilled and knowledgeable
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Case Management

Case management focuses on the administrative issues of health care, rather than the actual delivery
of health care. An RN case manager evaluates a patient’s care to determine her healthcare costs and
the likelihood that the insurer will provide coverage. Case managers follow the progression of a
patient’s care to determine the likely discharge date and her care needs after discharge.

The case management model stems from the complexity of third-party healthcare payers and the rising
costs of healthcare. A case manager serves as an intermediary between the patient and third-party
payers, which may include insurance companies, Medicare, or Medicaid. They also ensure that third-
party payers will reimburse the healthcare facilities for services.

Case managers often deal with 12 to 28 patients per day. In the past, they reviewed patient charts and
communicated with third-party payers every three to seven days. But in today’s digital age, case
managers communicate daily with attending doctors, nurses, and third-party payers.
Effective case management benefits everyone involved. The case manager communicates with the
patient to inform her about approvals or denials from her healthcare provider. Likewise, the case
manager can help prevent healthcare facilities from losing money because of unexpected coverage
denials.

Case managers must stay abreast of every aspect of the patient’s care, from diagnostic tests to surgery
schedules and from outpatient therapies to home healthcare requirements. For example, a case
manager must keep track of the number of days a patient’s insurance company will pay for inpatient
care. If a patient experiences a discharge delay due to a rescheduled surgery, the case manager must
communicate with the third-party payer and coordinate new surgery and discharge dates with
healthcare staff. A case manager must work closely with the patients to assess the effectiveness of
treatments and help devise self-care plans for after discharge.

Case Method

The case method also known as the individual method or total patient care approach corresponds to
a situation where a single nurse assumes full responsibility for delivering care to a group of patients
during a shift. Although care is not fragmented, its coordination does not prevail between shifts, and
changes may occur in the established nursing care plan. In this method, the overall organization of
care to meet the needs identified by the nurse depends on the nurse’s view of his/her role as a
professional and may prioritize the patient or the performance of tasks (Figure 4). In addition, and
because the individual method limits the nurses’ action during a shift and the patient(s) to which
he/she is allocated, outcome evaluation is based only on circumstantial objectives. The coordination
of the care delivered to all patients in the unit is under the responsibility of a single nurse, usually the
head nurse, who supervises and evaluates the delivery of nursing care and makes the most significant
decisions throughout the process. However, care delivery in that shift is delegated to the nurse
allocated to that shift.

This method has the following advantages for patients: the individualization of care, with the
satisfaction of their needs; it promotes the nurse-patient relationship; the patient can identify the nurse
who provides care in a given shift, resulting in a close, humanized, and personalized care, which also
reinforces the confidence in the nurse and the patient’s safety.
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This method also has some disadvantages/weaknesses. For patients, as each nurse will provide care
to different patients in each shift, there is no nurse or figure of reference to whom he can talk to during
the hospital stay as “his/her” primary nurse. Due to differences in individual skills and knowledge of
the nurses who provide care, asymmetry can be created in care delivery, leading to heterogeneity in
the several shifts related to different levels of care being delivered. For nurses, it has some potential
for emotional involvement with the patients and requires a higher level of proficiency from all nurses.
For organizations, it requires more staff than the task-oriented method.

Innovative/Contemporary Method

With the ongoing transformation of health care delivery, new care models that partner physicians and
hospitals as co-leaders of the clinical enterprise are rapidly emerging.

Once successful features of innovative care models and practices are identified, they need to be
“installed.” The concept of “install” is meant to be provocative. Installation must be driven by a
performance-based culture as well as systems and processes that support the features bundled. The
installation consists of three key strategies: the building will, harvesting ideas, and execution. Building
will is establishing an environment ripe for improvement. Within such an environment, ideas can be
harvested and executed. The three components of installing successful features must occur at every
level and throughout the organization.

Installing innovative care models, such as the Perioperative Surgical Home and Hospital at Home,
involves an entire system, not just one service line or one specialty. Installation requires disruption,
with a cultural context to support it. A culture within which disruption can occur is one built on
alignment, shared vision, shared purpose, communication, identifying champions, and continuity of
care.
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https://www.aha.org/system/files/media/file/2019/05/Innovative-Models-of-Care.pdf

Modular Nursing

Modular nursing: Similar to the team-based approach, where the unit is divided into quadrants
and teams are assigned to each.

This is a modification of team and primary nursing. It is a geographical assignment of patients that
encourages continuity of care by organizing a group of staff to work with a group of patients in the
same locale.

Advantages:

§ Useful when there are a few RNs

§ RNs plan their care

Disadvantage:

§ Paraprofessionals do technical aspects of nursing care

1.2. ACTIVITY ASYNCHRONOUS ACTIVITY (Submission Date: October 21, 2022@5pm

through Google Classroom) MIDTERM REQUIREMENT
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Task:

1. Formulate a plan of care to address the health conditions, needs, problems, and issues based on the
priorities of the patient.

2. Develop or create a health education program using selected planning models for your target
clientele.

Sample Health Programs of the Department of Health

Steps for planning a Health Program:

STEP 1: MANAGE THE PLANNING PROCESS

Purpose: to develop a plan to manage stakeholder participation, timelines, and resources, and
determine methods for data-gathering, interpretation, and decision-making.

Plan to engage stakeholders, including clients and staff, in a meaningful way. Establish a clear
timeline for creating a work plan. Plan how you will allocate financial, material, and human resources.
Consider the data required to make decisions at each step and include adequate time for data collection
and interpretation. Establish a clear decision-making process. (e.g., by consensus, by committee)
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STEP 2: CONDUCT A SITUATIONAL ASSESSMENT

Purpose: to learn more about the population of interest, trends, and issues that may affect
implementation, including the wants, needs, and assets of the community.

This step involves identifying: what is the situation; what is making the situation better and what is
making it worse; and what possible actions you can take to address the situation. Use diverse types of
data (e.g. community health status indicators, stories/testimonials; evaluation findings; “best practice”
guidelines), sources of data (e.g. polling companies; community/partner organizations; researchers;
governments; private sector); and data collection methods (e.g. stakeholder interviews or focus
groups; surveys; literature reviews; review of past evaluation findings or stakeholder
mandates/policies).

STEP 3: IDENTIFY GOALS, POPULATIONS OF INTEREST, OUTCOMES, AND

OUTCOME OBJECTIVES

Purpose: to use situational assessment results to determine goals, populations of interest, outcomes,
and outcome objectives.

Ensure program goals, populations of interest and outcome objectives are aligned with the strategic
directions of your organization or group:

• • goal: a broad statement providing overall direction for a program over a long period of time.
• • population(s) of interest: group or groups that require special attention to achieve your goal
• • outcome objective: brief statement specifying the desired change caused by the program

STEP 4: IDENTIFY STRATEGIES, ACTIVITIES, OUTPUTS, PROCESS OBJECTIVES,

AND RESOURCES

Purpose: to use the results of the situational assessment to select strategies and activities, feasible with
available resources, that will contribute to your goals and outcome objectives.

Brainstorm strategies (e.g. health education, health communication, organizational change, policy
development) for achieving objectives using one or more health promotion frameworks such as the
Ottawa Charter for Health Promotion or the socioecological model. Prioritize ideas by applying
situational assessment results. Identify specific activities for each strategy, including which existing
activities to start, stop, and continue. Select outputs and develop process objectives. Consider
available financial, human and in-kind resources.

STEP 5: DEVELOP INDICATORS

Purpose: to develop a list of variables that can be tracked to assess the extent to which outcome and
process objectives have been met.

For each outcome and process, the objective considers the intended result and whether: the intended
result can be divided into separate components; the intended result can be measured; there is an
appropriate time for observing a result; required data sources are accessible, and the resources needed
to assess the result are available. Define indicators to measure each outcome and process objective
and perform a quality check on proposed indicators ensuring they are valid, reliable, and accessible.
Indicators are used to determine the extent to which outcomes and process objectives were met.
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STEP 6: REVIEW THE PROGRAM PLAN

Purpose: to clarify the contribution of each component of the plan to its objectives, identify gaps,
ensure adequate resources, and ensure consistency with the situational assessment findings.

A logic model is a graphic depiction of the relationship between all parts of a program (i.e., goals,
objectives, populations, strategies, and activities) and is one way in which a program overview can be
communicated. Review the plan to determine whether: strategies effectively contribute to goals and
objectives; short-term objectives contribute to long-term objectives; the best activities were chosen to
advance the strategy; activities are appropriate to the audiences, and the resources are adequate to
implement the activities.

RUBRIC

ASSESSMENT CRITERIA PERCENTAGE

Describes and analyzes the case problem using selected planning models for your 25%
target clientele.
Appropriately uses the principles of qualitative research to understand and analyze 20%
the problem of the assigned case.
Formulates a plausible and creative health promotion and disease prevention 25%
strategy in accordance with the problem of the assigned case.
Adequately references the sources used in the paper. 15%
Writing, grammar, and spelling fulfill the expectations for academic compositions 15%
at the university level.
TOTAL 100%

1.3 REFERENCES

American Hospital Associations. Innovative Models of Care Delivery: Addressing Transitions Across
The Care Continuum. American Hospital Association 155 North Wacker Drive • Chicago, IL
60606www.ahaphysicianforum.org.
https://www.aha.org/system/files/media/file/2019/05/Innovative-Models-of-Care.pdf

Daisy Jane Antipuesto RN MN. Modalities of Nursing Care. Fundamentals of Nursing. Nursingcrib.
2022. https://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-nursing/modalities-of-
nursing-care/

Daniela Couto Carvalho Barra and Grace Teresinha Marcon Dal Sasso. Th Nursing Process
According to the International Classification For Nursing Practice: An Integrative Review.
Literature Review. 88037-500 – Córrego Grande, Florianópolis, SC, Brasil E-mail:
danyccbarra@yahoo.com.br. Text Context Nursing, Florianópolis, 2012 Abr-Jun; 21(2): 440-7.
https://www.scielo.br/j/tce/a/VNnD8sjTK9qKgPMmdFbShZz/?lang=en&format=pdf

HealthStream. Understanding the Primary Model. © 2022 HealthStream

https://www.healthstream.com/resource/blog/understanding-the-primary-nursing-care-model
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Mattew Grant et al. A systematic review of classifications systems to determine complexity of patient
care needs in palliative care. Palliative Medicine. Palliat Med. 2021 Apr; 35(4): 636–650.
Published online 2021 Mar 12. National Library of Medicine, National Center for
Biotechnology Information. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022082/

Michael Evans. Types of Nursing Modalities. Career Trends. Copyright 2022 Leaf Group Ltd. / Leaf
Group Media, All Rights Reserved. https://careertrend.com/info-8520558-types-nursing-
modalities.html

Oliveira JLC, Cucolo DF, Magalhães AMM, Perroca MG. Beyond patient classification: the “hidden”
face of nursing workload. Rev Esc Enferm USP. 2022;56:e20210533.
https://doi.org/10.1590/1980-220X-REEUSP-2021-0533en.
https://www.scielo.br/j/reeusp/a/mgnLNV4Mf6TGfLYsFY5hTkC/?format=pdf&lang=en

Pedro Parreira et al. Work Methods for Nursing Care Delivery. National Library of Medicine:
National Center for Biotechnology Information. Int J Environ Res Public Health. 2021 Feb;
18(4): 2088. Published online 2021 Feb 21. doi: 10.3390/ijerph18042088
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7924841/

Stonehouse, DP. Nursing Process or Process of Care: Understanding the Nursing Process.
Understanding the nursing process. British Journal of Healthcare Assistants , Mark Allen Group
2017.

Zona Taylor. The Health Care Delivery System: The US and Worldwide. Social Science
Courses / Introduction to Political Science: Tutoring Solution / Public and Social Policy:
Tutoring Solution. © copyright 2003-2022 Study.com. https://study.com/academy/lesson/the-
health-care-delivery-system-the-us-and-worldwide.html

https://doh.gov.ph/blhsd/health-service-delivery

https://www.mjc.edu/instruction/alliedhealth/adnprogram/nursingprocessoverview.pdf

https://muschealth.org/patients-visitors/about-us/nursing/musc/care

https://www.nursingguide.ph/category-career-guides/the-patient-classification-system

https://www.publichealthontario.ca/-/media/documents/s/2015/six-steps-planning-hp-
programs.pdf?sc_lang=en

https://www.researchgate.net/figure/Assessment-rubric-for-Health-Promoting-University-
project_tbl1_305876719

https://usir.salford.ac.uk/id/eprint/46573/7/Understanding%20the%20Nursing%20Process.pdf

https://study.com/learn/lesson/health-care-delivery-system-concept-components-types.html

https://www.thecommunityguide.org/content/program-planning-resource
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1.4 ACKNOWLEDGMENT

The images, tables, figures, and information contained in this module were taken from the
references cited above.

Prepared by:

MARY ANN D. APACIBLE, MAN EdD (CAR)

Clinical Instructor-Instructor I
College of Nursing - Samar State University