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.