Community Resources and Referrals
Home health nurses and
public health nurses act as case managers. After assessing the patient’s
needs, they may make referrals to other team members, such as home health aides
and social workers. They work collaboratively with the health team and the
agency or person who referred the patient for service. Continu-ous coordinated
care among all health care providers involved in the patient’s care is
essential to avoid duplication of effort by the various personnel caring for
the patient.
Home care and public
health nurses are responsible for pro-viding the patient and family with
information about other com-munity resources that are available to meet their
needs. During the initial and subsequent visits, they help patients identify
these community services and encourage the patient and family to con-tact the
appropriate agencies. When appropriate, the nurse makes the initial contact
(Pierson, 1999).
A community-based nurse
needs to be knowledgeable about community resources available to patients as
well as services pro-vided by local agencies, eligibility requirements, and any
possible charges for the services. Most communities have directories of health
and social service agencies that the nurse can consult. These directories need
to be continually updated as resources change. If a community does not have a
resource booklet, the agency may develop one for its staff. It should include
the com-monly used community resources that patients need, the costs of the
services, and eligibility requirements. The patient’s place of worship or
parish may serve as an important resource for services. The telephone book is
often a useful resource for helping patients identify the locations of grocery
and drug stores, banks, health care facilities, ambulances, physicians,
dentists, pharmacists, social service agencies, and senior citizens programs.
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