1. In your own words and using the appropriate evidence-based references, define family and describe the different types of family.2. Identify characteristics of the family that have implications for community health nursing practice.3. Discuss a model of care for families.4. Describe strategies for moving from intervention at the family level to intervention at the aggregate level.Present your assignment in an APA format word document, Arial 12 font for grading and in the tab titled. A minimum of 2 evidence-based references besides the class textbook must be used. A minimum of 700 words is required.
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Chapter 9
Case Management
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
Case Management …
“… is a collaborative process of assessment,
planning, facilitation, care coordination,
evaluation and advocacy for options and
services to meet an individual’s and family’s
comprehensive health needs through
communication and available resources to
promote quality cost-effective outcomes.”
– The Case Management Society of America (2009)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Nursing Case Management …
… is “a dynamic and systematic collaborative
approach to provide and coordinate health care
services to a defined population. The framework
includes five components: assessment,
planning, implementation, evaluation and
interaction.”
– American Nurses Credentialing Center, ANA
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Care Management
Overall goal: Improve the coordination of
services provided to clients who are enrolled in
a care management program.


A collaborative process
An emerging concept that is…

evidence based
➢ patient centered
➢ clinical care focused
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Care Coordination

Target chronically ill persons at risk for
adverse outcomes and expensive care

Identify full range of problems that increase
patients’ risk of adverse health events
➢ Educate in self-care, optimization of treatment,
and integration of care
➢ Monitor patients for progress and early signs of
problems

Hope to raise quality of care, improve health
outcomes, and reduce need for costly
hospitalizations and medical care
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Patient-Centered Medical Homes

Seven characteristics:







Patient’s relationship with primary care physician
Physician-led, team-based care
“Whole persons” require comprehensive care at
various stages of life
Integration and coordination of care
Quality and safety
Improved access to care
Payment system that accurately reflects the efforts
and care provided by the team
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Purposes of Case Management

Client centered


Help the client through a complex, fragmented,
and often confusing health care delivery system
and achieve specific client-centered goals.
System-centered


Recognizes that resources are finite
Promote cost-effective, high-quality care
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Possible Case Management
Functions







Identifying the target
population
Determining screening
and eligibility
Arranging services
Monitoring and followup
Assessing
Planning care
Reassessing


Helping clients through
a complex, fragmented
health care system
Care coordination and
continuity
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Case Managers



Must have appropriate educational
background
A minimum skill level is needed to ensure
success in the role
Certification as a case manager is available

Case Management Association of America
(CMSA)
➢ American Nurses Credentialing Center (ANCC)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Role Functions of Case Managers
(CMSA, 2002)

Essential activities of case management

Assessment
➢ Planning
➢ Facilitation
➢ Advocacy
➢ Collaboration
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Case Management in Community
Health




Community case management models
Public health clinic settings
Occupational health settings
High-risk clinic settings




Clients with chronic diseases
Home health and hospice
Case management research
International settings
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Chapter 20
Family Health
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
Working with Families



Working with families has never been more
complex or rewarding than now.
Nurses understand the actual and potential
impact that families have in changing the
health status of individual family members,
communities, and society as a whole.
Families have challenging health care needs
that are not usually addressed by the health
care system.
.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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How Do You Define a Family?
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
3
Definitions of a Family
Historical definitions:
 The environment
affecting individual
clients
 Small to large groups of
interacting people
 A single unit of care with
definable boundaries
 A unit of care within a
specific environment of
a community or society
Current theorists:
 Two or more individuals
who depend on one
another for emotional,
physical, and economic
support. Members of
family are self-defined.
– Hanson & Kaakimen (2005)

The family is who they
say they are.
– Wright & Leahey (2000)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Inclusive Definitions of Family
“Family” means any person(s) playing a significant role
in an individual’s life. This may include person(s) not
legally related to the individual. Members of “family”
include spouses, domestic partners, and both differentsex and same-sex significant others. “Family” includes a
minor patient’s parents, regardless of gender of either
parent … without limitation as encompassing legal
parents, foster parents, same-sex parent, step-parents,
those serving in loco parentis, and others operating in
caretaker roles.
– Human Rights Campaign ( 2009)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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The Changing Family

Purposes of the family



To meet the needs of society
To meet the needs of individual family members
Examples of different family types

Traditional, nuclear family
➢ Multigenerational family household
➢ Cohabitating families
➢ Single-parent families
➢ Grandparent-headed families
➢ Gay or lesbian families
➢ Unmarried teen mothers
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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The “Sandwich” Generation
Figure 20-1 From Pew Research Center: Social and Demographic Trends: The Sandwich
Generation. http://www.pewsocialtrends.org/2013/01/30/the-sandwich-generation/. Accessed March
15, 2013.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Why Is It Important for the CHN to
Work with Families?




The family is a critical resource.
Any dysfunction in a family unit will affect the
members and the unit as a whole.
Case finding can identify a health problem
that leads to risks for the entire family.
Nursing care can be improved by providing
holistic care to the family and its members.
– Friedman, Bowden, & Jones (2003)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Approaches to Meeting the Health
Needs of Families
Moving from
the Individual
to the Family
Moving from
the Family to
the
Community
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Moving from the Individual to the
Family

Family interviewing

Manners
➢ Therapeutic conversations
➢ Genogram and Ecomap
➢ Therapeutic questions
➢ Commending family or individual strengths
➢ Issues in family interviewing
• Many locations, family informant, family health portrait,
involvement of children

Intervention in cases of chronic illness
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Moving from the Family to the
Community






The health of communities is measured by
the well-being of its people and families.
Families are components of communities.
Cross-comparison of communities must
include health needs as well as resources.
Cross-compare the needs of the families
within the community and set priorities.
Delegation of scarce resources is essential.
A double standard in public health is
tolerated.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Family Theory Approach
1. Any “dysfunction” that affects one member will
probably affect others and the family as a whole.
2. The family’s wellness is highly dependent on the role
of the family in every aspect of health care.
3. The level of wellness of the whole family can be
raised by reducing lifestyle and environmental risks
by emphasizing health promotion, self-care, health
education, and family counseling.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Family Theory Approach (Cont.)
4. Commonalities in risk factors and diseases
shared by family members can lead to case
finding within family.
5. Individual is assessed within larger context of
family.
6. Family is vital support system to individual
member.
– Friedman (1994)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Systems Theory Approach
The family as a unit interacts
with larger units outside the
family (suprasystem) and with
smaller units inside the family
(subsystem).
– Friedman (1998)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Healthy Families




Members interact with each other; listen and
communicate repeatedly in many contexts.
Healthy families establish priorities. Members
understand that family needs are the priority.
Healthy families affirm, support, and respect each
other.
Members engage in flexible role relationships, share
power, respond to change, support the
growth/autonomy of others, and engage in decision
making that affects them.
– DeFrain (1999) and Montalvo (2004)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Healthy Families (Cont.)




The family teaches family and societal values and
beliefs and shares a religious core.
Healthy families foster responsibility and value
service to others.
Healthy families have a sense of play and humor and
share leisure time.
Healthy families have the ability to cope with stress
and crisis and grow from problems. They know when
to seek help from professionals.
– DeFrain (1999) and Montalvo (2004)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Structural-Functional Conceptual
Framework

Internal structure


External structure




Family composition, gender, rank order, functional
subsystem, and boundaries
Extended family and larger systems (work, health, welfare)
Context: ethnicity, race, social class, religion, environment
Instrumental functioning (routine ADLs)
Expressive functioning

Emotional, verbal, nonverbal, circular communication;
problem solving; roles; influence; beliefs; alliances and
coalitions
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Developmental Theory

Family life cycle (Duvall & Miller,
1985)







Leaving home
Beginning family through marriage or
commitment as a couple relationship
Parenting the first child
Living with adolescent
Launching family (youngest child leaves
home)
Middle-age family (remaining marital
dyad to retirement)
Aging family (from retirement to death of
both spouses)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Family Health Assessment Tools

Genogram


Family health tree


A tool that helps the nurse
outline the family’s
structure
Family’s medical and
health histories
Ecomap

Depicts a family’s linkages
to their suprasystems
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Family Health Assessment Tools

Family Health Assessment

Addresses family characteristics,
including structure and process and
family environment
➢ Information obtained through
interviews with one or more family
members, subsystems within the
family, or group interviews of more
than two members of the family
➢ Additional information obtained
through observation of family and
their environment
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Genogram
Figure 20-2 Redrawn from Genopro Software: Symbols used in genograms, 2009: www.genopro.com.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Ecomap
Figure 20-4 Redrawn from Hartman A: Diagrammatic assessment of family relationships, Soc
Casework 59:496, 1978.
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Social and Structural Constraints


Identify what prevents families from receiving
needed health care or achieving a state of
health
Usually based on social and economic
causes



Literacy, education, employment
If disadvantaged, often unable to buy health care
from private sector
Hours of service, distance and transportation,
availability of interpreters, and criteria for receiving
services (age, sex, income barriers)
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Family Health Interventions

Institutional context of family therapists



Ecological framework: A blend of systems and
developmental theory that focus on the interaction
and interdependence of families within the context
of their environment
Social Network Framework: Involves all
connections and ties within a group; social support
Transactional model: A system that focuses on
process as opposed to a linear approach
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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Applying the Nursing Process



Knowledge of self, previous life experiences,
and values is crucial in planning home visits
Gather referral information, review
assessment forms, and gather intervention
tools (e.g., screening materials, supplies)
before going to the home
Flexibility is important in working with families
Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
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