Nursing Fundamentals: Caring and Clinical Decision Making – Health System Example

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"Nursing Fundamentals: Caring and Clinical Decision Making" is a great example of a paper on the health system. Continuum of care is a program aimed at settling the homeless and remove them from the trauma associated with homelessness as well as seek to enroll them into programs that can assist them to prevent homelessness in the future and assist their families in survival as well (Byron, 2009). Case management is the facilitation and management collaboratively of the health care services for the individuals and the community in a bid to promote quality while ensuring the cost is effective and affordable (Leonard and Miller, 2012). Case managers are tasked with the role of being the ones in charge of ensuring that the people in the continuum of care program transition effectively.

This means that they take care of all their needs and ensure that once they leave the hospital or health care setting, they move through rehabilitation, nursing, social work, and family to the family and community without any difficulties. The aim is to enable the people in such a program to feel like part of the community without flooding them but instead using the multi-steps approach taking things slowly step by step. Continuum of care in case management also means that the people under the continuum of care program have all their medical, psychological, financial, and familial needs taken care of by the case managers.

The case managers, therefore, coordinate with various individuals and departments starting from the doctors and nurses in the hospitals to the social workers and the family of the individuals in this program to ensure that once they leave the health care setting, they will be ready to transition to the stages mentioned above without any hitch or delay.   What are some of the weaknesses of discharge planning as it is practiced in acute care settings today?

How could this be improved using a case management model? The majority of the patients are in acute care settings and hence when it comes to discharging planning, there emerge a few weaknesses. One of these weaknesses is in the documentation. Documentation demands signatures and confirmations from various doctors who have treated the patient.

Considering the number of patients the doctor has had to handle and needs to handle, documentation is delayed hence delaying the whole discharge plan process. The number of people being handled under the continuum of care program by the case managers and who are in the discharge planning outnumber the case managers; this, therefore, slows down the work and is one of the greatest weaknesses. There is also no standardized discharge plan created through a policy. This, therefore, means that each care facility has its own discharge plan and for acute settings, this is not ideal (Daniels, 2003). The model should be used as a guideline to speed up the process of preparing a discharge plan through dividing the functions of the case managers present so that each case manager is allocated specific functions and carrying out several functions at once.

This will mask the shortage of weakness. The guidelines if used by all case managers in the different care facilities will act as a standardized policy hence a lack of disparities in acute care settings (Frankel and Gelman, 2012).  


Byron, S. (2009). A Continuum of Care for Homeless People. Arizona: Arizona State University.

Daniels, R. (2003). Nursing Fundamentals: Caring & Clinical Decision Making. New York: Cengage Learning.

Frankel, A. and Gelman, S. (2012). Case Management: An Introduction to Concepts and Skills. Illinois: Lyceum Books Incorporated.

Leonard, M. and Miller, E. (2012). Nursing Case Management Review and Resource Manual, (4th Ed.). Maryland: American Nurses Credentialing Centre.

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