A Guide to Implementing Best Practices in Person ... - cancerview.ca

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Navigation: A Guide to Implementing Person-Centred Care September 2012ServicesProvided inSevenSupportiveCareDomains1.Informational• intervenes within scope of practice on patient’s andfamily’s behalf• establishes linkages and coordinates care amongagencies and service providers• provides direct referrals, as desired by patient orfamily, to other professionals and services• provides education about disease and related issuesand self-care• provides emotional support during cancer journey• works with patient, family and community tofacilitate transitions• provides information, support and guidance indecision-making• has access to medical records• maintains record of navigation in accordance withinstitutional standards and privacy legislationInformation and advice about disease, process of treatment,side-effects, services, quality of life, adaptationand changes in ability; instruction in self-management;assistance in decision-making2. Psychological Comprehensive assessment; professional interventionbased on standards of practice; facilitated referral asneeded3. Emotional Comprehensive assessment; professional interventionbased on standards of practice; facilitated referral asneeded; support in dealing with family’s reactions;support for patient and family to express needs to careteam; identification of and building on patient’s andfamily’s strengths4. Spiritual Comprehensive assessment; professional interventionbased on standards of practice; facilitated referral asneeded• supports communication with health careproviders• may intervene at certain points or throughoutthe cancer journey• may advocate for patient through health careteam within role guidelines• assists with record-keeping in accordance withpatient and/or organizational requirements andprivacy legislationInformation about self-management, tips, services;information about cancer journey process;peer/lay perspective on experience of cancer;support decision-making; encouragement to seekhelp from professionals and community organizationsIdentification of concerns, response, validation;peer/lay perspective on experience; offer ofhope; encouragement to seek help from professionalsand community organizations; referral toresourcesIdentification of concerns, response, validation;peer/lay perspective on experience; normalizationof experience; encouragement to seek help fromprofessionals and community organizationsIdentification of concerns, response, validation;peer/lay perspective on experience; encouragementto seek help from professionals and communityorganizations60
Navigation: A Guide to Implementing Person-Centred Care September 2012Scope ofPractice inKey Areas5. Physical Comprehensive assessment; specific professionalinterventions and facilitated referral as needed; followupon interventions used; consideration of medicalhistory; information about possible symptoms, symptomand pain management; medication changes; decreasedfragmentation across care team throughout thecontinuum of care6. Social Comprehensive assessment; professional interventionbased on standards of practice; facilitated referral asneeded; provides broad perspective to care team aboutspecific patient and family situation7. Practical Comprehensive assessment; professional interventionbased on standards of practice; facilitated referral asneededAssessing needs andexisting resources/strengthsEducationAccessSupportProvides systematic screening/triage and comprehensiveclinical assessment for patients and families using standardized,evidence-based toolsOffers standard and personalized medical and psychosocialinformation and explanation for patient and family,throughout the continuum of care, based on expertknowledge/skill set in oncologyProvides direct referrals to other professionals andservices as required following clinical assessmentProvides emotional/psychological support; aids withdecision-making based on expert clinical knowledge;focuses on empowerment, building on patient’s andfamily’s strengths and resourcesIdentification of concerns, response, validation;peer/lay perspective on experience; encouragementto seek help from professionals for medicalconcernsIdentification of concerns, response, validation;peer/lay perspective on experience; encouragementto seek help from professionals and communityorganizationsIdentification of concerns, response; validate;offer peer/lay perspective on experience;encouragement to seek help from professionalsand community organizations; some directservices (e.g., filling out forms, connecting totransportation, translation)Within scope of role, identifies needs andresponds to concerns identified by patient andfamilyProvides information about patient experience:identifies expected events and related concerns;provides basic health care informationEncourages help-seeking from professionals; mayfacilitate referrals to professionals in some cases,according to defined scope of role; providescontacts for practical and support servicesProvides emotional support based on extensivepeer/lay support training and/or experience; supportspatient decision-making; helps to empowerthe person61
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