Section II - Discharge Planning and Home Management
Community Services
Community Health Nurses:
- Collaborate with the hospital staff to ensure continuity of care for the patient and family.
- Attend orientation and inservices provided by an Apnea Program.
- Knowledgeable in infant monitoring and BCLS certified through the American Red Cross or America Heart Association.
- Establish contact with the patient and family within 24 hours of hospital discharge.
- Assess and reinforce the parents' recall/understanding of information provided during the patient's hospitalization as listed above.
- Provide patient assessment as indicated.
- Review the infant's physical care needs with parents.
- Assist the family in identifying additional community resources as needed, e.g. respite care.
- Review and support the patient's normal growth and development with emphasis on incorporating the child into the normal family structure.
- Review and clarify plans for follow-up medical care.
- Refer observation of abnormal findings and/or necessary changes in care regimen or related equipment to the appropriate provider.
- Refer concerns regarding compliance to the primary care physician and, if involved, the Apnea Program.
- Prepare the family for the eventual discontinuation of treatment.
- Offer emotional support and validation of the parents' reactions to their infant's diagnosis and treatment.
- Determine with the family, the managing physician and, if involved, the Apnea Program coordinator, the frequency and length of service.
Michigan Department of Public Health and Children's Special Health Care Services:
- Information about applications and reimbursement of skilled home nursing services may be found in the CCP Policy and Procedures for Pediatric Home Health Services (October, 1987).