Continuity of Care

[shannonFNP, BSN, MSN, RN]

Hi everyone! I was wondering what your facility does to help with continuity of care. We have "case conference" every Monday of patients that are about to reach their EOE and that's when we get some limited information from the people that even show up. As an RN it makes it very difficult to recert someone or Dc you might not have even admitted without any more information than a quick "her wound looks good."

Just looking for tips. We have Cerner RoadNotes (terrible!!!!!!!) that does have a place for "plan for next visit" that will actually show up on the next person's computer screen when they go out. We are having issues with everyone using their computers however.

There's no report like I'm used to in the hospital, but I think there should definitely be more continuity of care!

[caliotter3]

Only two agencies I have ever worked for did anything along the line of case conferences, and one of them was because I suggested it. Other agencies, including the one I am with now, don't even bother to inform the field nurses who the current nursing supervisor, case manager is for each case. For that matter, we have a new Director of Clinical Services. I haven't had a conversation with either her(?) or her predecessor. I have no idea what her(?) name is, or the previous person with that title. I have no idea who the nursing supervisor is, by name, face, or phone conversation. I know not to bother bringing up anything of consequence concerning my case. I would expect the same response as in the past. Nothing, absolutely nothing.

[shannonFNP, BSN, MSN, RN]

We're struggling with one CS for our entire census, 2 field RNs (including myself), and a newly hired DOCS that starts next week. Rough! I'm just trying to make things a little easier!

[caliotter3]

I think case conferences are very useful and should be made mandatory with some kind of required input, not just show your face and sit around the table like a lump on a log. Lots of problems can be dealt with and even avoided in this manner, and everyone is placed on the same sheet of music as the CS. But when you can't even get people to attend mandatory inservices, with threats to their personnel folder, they aren't going to be responsive to anything else that takes any effort.

[anticoagulationurse]

Not to be negative here but, personally I have never understood the point of a weekly case conference. If I have an issue or concern I deal with it now, in real time and inform/discuss with the people I need to and certainly don't wait until case conference to do so. I also read the progress notes of other disciplines if I am concerned or curious about something specific. So, to me case conference is a waste of my time and I am telling people things they could easily look up for themselves if they took the initiative.

We too have Cerner Roadnotes, and it is TERRIBLE! No spreadsheets, not user intuitiveness to it, makes it truly difficult and laborious to jump through pages and click a ton of buttons just to document a simple thing. I hate it.

[caliotter3]

Case conferences are useful because of field nurses who do not attend to matters ever, much less on a day to day basis. Situations found more so in the extended care realm, where everything is shoved aside until something blows up in someone's face. I don't see where matters are allowed to get to that state in intermittent care, for the most part.

[shannonFNP, BSN, MSN, RN]

Don't get me wrong, I definitely take care of my important things right away! The case conference is only over the people reaching their EOE and for SOCs. The clinical supervisor gets report daily, but the RN's never get it and we don't have case managers. I guess we are the case managers? Anyway, I see our 170ish census of patients maybe once or twice, or NEVER, before they're up for me to recert. I just need SOMETHING that tells me how this patient has been doing! Our documentation system just makes it too difficult to look up the notes before hand, and many of our LVN's don't write discipline summaries so it makes it hard as an RN, at least in my case.