Integrating principles of primary health care in discharge planning
Joe, a client admitted into the medical unit, is preparing for discharge after being treated for Chronic Obstructive Pulmonary Disease (COPD) exacerbation. Joe is in his mid-70s and lives alone at home. He is on social assistance and does not leave the house much since he does not have access to a vehicle. When he does need to leave the house, Joe uses public transit. Joe’s daughter lives two hours away, but due to her busy schedule, she doesn’t visit often. However, a close family friend does check-up on Joe once in a while. Nicole, the nurse caring for Joe, meets with the interprofessional team during rounds, and uses the principles of primary health care to support Joe’s discharge planning.
Based on Nicole’s understanding of CARNA’s Practice Standards for Regulated Members (2013), she recognizes her responsibility to communicate effectively with clients and other members of the health care team; coordinate client care activities to promote continuity of health services; and collaborate with the client and health care team regarding activities for care planning, implementation and evaluation. Nicole also understands that a key ethical responsibility of promoting health and well-being is recognizing and using the values and principles of primary health care, as indicated in the Canadian Nurses Association (CNA) Code of Ethics (2017). Further, the principles and values of primary health care can be integrated across all settings such as in acute care, and across the continuum in order to support comprehensive, equitable, accessible and client-centered care (CARNA, 2020).
Using the principles of primary health care, Nicole brings several considerations forward to the interprofessional team to ensure adequate supports and services are in place for Joe’s successful transition back home. She starts by reflecting on the social determinants of health and considers how they have and will impact Joe’s health.
- Does Joe have access to a primary health care provider and adequate follow up?
- Nurses hold the role of navigator and coordinator. What steps can Nicole and the team take to ensure continuity of care?
- How is Joe being included in discharge planning discussions?
- What options regarding supports and services can Joe consider to support informed decision making and client-centered care?
- As a registered nurse, one of Nicole's roles is to engage in health teaching. What can she do to promote Joe's health and health literacy?
- How can the environment in which Joe lives be modified to better support healthy living?
- What community resources would support Joe's health and well-being?
- Are there appropriate forms of technology that can be used to support Joe at home?
- What services outside of the health system could support Joe, such as social services for meals, transportation services, banking, or community supports to address social isolation?
Disclaimer: Our case studies are fictional educational resources. While we strive to make the scenarios as realistic as possible, any resemblance to actual people or events is coincidental.