Patient Centered Care

SHERRY RIVERA DNP, APRN, ANP-C

LSU HEALTH NEW ORLEANS SCHOOL OF NURSING
Learning Objectives
By the end of this lecture the learner will be able to:
◦ Obtain and interpret the health history for older adults and patients that live
in rural areas
◦ Describe the components of a wellness exam (initial, annual, subsequent)
◦ Conduct a person-centered physical exam and for patients living in rural areas
◦ Identify individual risk factors from the health history and determine
appropriate preventive screening recommendations
◦ Demonstrate proficiency in systematically documenting patient assessment
findings using standard terminology for patient centered exams, telehealth,
and wellness visits
 Pregnancy
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Rural Health
Populations
◦ Older adults
◦ Lower income
◦ Medicare/Medicaid
◦ Healthcare Provider Shortage Area
Occupations
◦ Agriculture
Health Assessment
• Health is based on the ability to work or daily activities
• Self-reliance- challenge with health promotion
• Mistrust in providers may be present
Social Determinants of Health Vital Sign
Living situation Family and Community Support
Food Insecurity Education
Transportation Physical Activity
Utilities Substance Use
Safety Mental Health
Financial Strain
Employment
 Older
Adult
Population
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Geriatric Assessment
Goals of Care
Site of Care
Frailty
Time Constraints
Availability of Interprofessional Team Members
Geriatric Assessment
Social Medications
◦ Social support Fall Risk
◦ Elder Neglect/ Support Continence
◦ Advance Directives Weight Loss
Sleep
Functional
◦ Driving Pain
◦ Daily activities Alcohol Abuse
◦ Vision Cognition and Affect
◦ Hearing Depression
Cognition

Geriatric Syndromes
 Risk vs. benefit

Life expectancy
Principles of
Screening and
Treatment
Patient’s goals

Level of function
 Management
Considerations
• Screening
• Bone density
• HTN
• DM
• Lipid
• Colorectal
• Mammo
• Pap
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 Medical Decisions Self Care

Competence

Finances Consent
 Basic

Activities of
Instrumental
Daily Living

Executive
Frailty
•Chronic progressive condition
•Primary frailty is related to aging process
•Secondary frailty is usually related to end stage disease
•Vulnerability related to multisystem dysregulation
•Clinical presentation:
• Decreased muscle mass
• Loss of strength
• Decreased physical activity
• Slow movement
• Poor tolerance to activity
• Inadequate nutritional intake
 Unintentional weight loss of 10lbs or more within the
past year

Presence of exhaustion

Frailty
Diagnostic Slowness
Measured by length of
time to walk 15 feet
Criteria
Low level of physical activity (less than 270 calories a
week)

Weakness Measured by grip strength

 •All individuals should be screened beginning at age 70
•Treat underlying conditions
•Address any modifiable factors
• Environmental
• Risk factors
Management • Functional
• Cognitive
Strategies • Social
• Nutritional
•Increase and maintain physical activity
•Culturally competent care
•Coordination of care
•Discuss with patient goals of treatment
 Identify risk factors

Falls and
Balance Ask all older adults about falls or
unstable gait
Disorders

Physical Exam Components

 Geriatric Syndromes
• Incontinence
• Delirium
• Falls
• Pressure ulcers
• Sleep disorders
• Eating problems
• Pain
•Depression
•Dementia
•Disability
Mental Health Issues
• Depression
• Dementia
• Suicide risk
• Delirium
• Dementia
 The • Hospital setting
Confusion • Treatment
Assessment • Identification and treatment of precipitating
causes
Method • Withdrawal of drugs

(CAM) • Supportive care

 Elder
Abuse
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Driving
Assessing and Guiding Older Drivers
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html
Transitions of Care
Re-Engineered Discharge
Transitional Care Model
Care Transitions Program
Better Outcomes for Older Adults through Safe Transitions
Interventions to Reduce Acute Care Transfers
 Telehealth

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Virtual Environment
Traditional presence vs. Virtual presence
◦ Meaningful communication
◦ Maintain a safe and secure space
◦ Experienced with technology
◦ Show interest, honesty, and transparency
Etiquette
◦ Environment (visual and auditory)
◦ Performance
◦ Privacy
Clinical Skills
Assessment Skills
Peripherals
Principles of Telehealth
Legal and Regulatory Issues
◦ Scope of Practice
◦ Licensing
◦ Credentialing
◦ Reimbursement
◦ Malpractice
Health Policy
Provider Availability
Financial Aspects
Patient and Provider Satisfaction
Telehealth Requirements
Introduce yourself
Confirm identity of the patient and anyone who is present in the room
Utilize equipment that is secure and HIPPA compliant
Conduct the visit in private
Assure the patient of:
◦ Security and HIPPA compliance of the platform
◦ Doors are closed
◦ Visit is not being recorded
◦ Information will not be shared
Telehealth Requirements
Notify the patient of who is located in the room
Inform the patient and family of the advantages and limitations of telehealth
Ensure access to care in emergency situations and back up plan if needed for
further evaluation
Keep detailed records
Adhere to guidelines
Collaborate and communicate with other health professionals as needed
Wellness Visit
Medicare Coverage
Initial Preventive Physical Exam
Medical and social history
◦ PMH, PSH
◦ Medications, supplements, vitamins
◦ Family history
◦ Social history
◦ Alcohol, tobacco, illicit drug
◦ Diet
◦ Physical Activities

Depression screening
Cognitive
Level of safety
Initial Preventive Physical Exam
Functional ability and level of safety
◦ Hearing
◦ ADLs
◦ Fall risk
◦ Home safety
Height/Weight/BMI
BP
Visual acuity
End of life planning
Initial Preventive Physical Exam
Review any current opioid prescriptions
Screen for potential substance use disorders
End of life planning
Referrals
Education, counseling, referrals as warranted
EKG and/or other preventive screenings as appropriate
Cardiovascular Screening
Fasting Lipid Panel
EKG
Lifestyle Risk Factors
Diabetes Screening Tests
Diagnosis of Diabetes
◦ Fasting BS >126mg/dl (2 separate occasions)
◦ 2 hour PP glucose >200mg/dl (2 occasions)
◦ Random glucose >200mg/dl
Prediabetes
Screening tests
Serum fasting glucose
Oral GTT
Frequency
Ultrasound Screening AAA
At least one risk category
◦ Family history
◦ Male age 65-75 with smoking history
◦ Additional risk factors as identified by USPSTF
Colorectal
Cancer
Screening
Other Screening Tests
Mammogram
Prostate Cancer Screening
Annual Wellness Visit
Purpose: To provide a personalized prevention plan
Conduct a health risk assessment (no more than 20 minutes)
◦ Demographic data
◦ Self assessment of health status, frailty, and physical functioning
◦ Psychosocial risks (depression, stress, fatigue)
◦ Behavioral risks
◦ Activities of daily living and risk for falls
◦ Instrumental activities of daily living
Annual Wellness Visit
Establish a medical and family history
Establish a list of current providers and suppliers involved in care of the patient
Obtain height, weight, BMI, BP, and additional as needed
Detect cognitive impairment (observation or as identified from family etc)
Functional ability and safety
◦ Hearing
◦ Ability to perform ADLs
◦ Fall risk
◦ Home safety
Annual Wellness Visit
Written screening schedule for the individual for the next 5-10 years
Create a list of risk factors or conditions which interventions are recommended
Provide personalized health advice and methods to reduce risk
◦ Wellness
◦ Physical activity
◦ Smoking cessation
◦ Fall prevention
◦ Nutrition
Annual Wellness Visit
Advance care planning
Evaluate risk factors for depression (screening tool)
Review the individual’s functional ability and level of safety(observation,
screening tools)
Review current opioid prescriptions
◦ Review risk factors for opioid use disorder
◦ Evaluate severity of pain and current treatment plan
◦ Provide info on non-opioid treatment options
◦ Refer to specialist as appropriate
Subsequent Annual Wellness Visits
Update
◦ Health risk assessment
◦ Medical and family history
◦ Provider and supplier list
◦ Screening recommendations and referrals
◦ Advanced Care Planning
◦ Opioid use and screening
Height, Weight, BMI, BP
Cognitive evaluation