MODALITIES OF CARE

Modalities of Nursing Care

It refers to the manner in which
nursing care is organized and
delivered. Depending on the:
● philosophy of the organization
● nurse staffing, and
● client population.
1. Case Method
2. Primary Nursing
3. Team Nursing
4. Modular Nursing
5. Functional Nursing
6. Nursing Case Management
7. Innovative/ Contemporary Method
1. Case Method / Total Patient Care
Nurses assume total responsibility for meeting all the needs of assigned patients during
their time of duty.

➔ It is the OLDEST mode of organizing patient care.

➔ Sometimes referred to as the case method of assignment because patients may be assigned
as cases
➔ Nurses assume total responsibility during their time on duty for meeting all the needs of
assign patients.
➔ The nurse cares for one or few patients whom the nurse cares for exclusively.
➔ Provides nurses with high autonomy and responsibility.
 Case Method
ADVANTAGES: DISADVANTAGES
❏ Quality of care—all care is ❏ It can be very costly.
delivered by a registered nurse ❏ Confusing to the patient of nurse
❏ Continuity of care for a given shift modifies care regimen during every
❏ High patient satisfaction shift.
❏ Tasks can be done by someone with
❏ Decreases communication time
less training, less experience and
between staff
low cost.
❏ Reduces the need for supervision
❏ Allows one person to perform more
than one task
Reference: https://nursekey.com/patient-care-management-2/
Structural Diagram of Total Patient Care

Charge Nurse

Nursing Staff

Nursing Staff

Nursing Staff

Patients

Patients
Patients
 An example of a patient care assignment using the total patient care model:

Hester B., RN, MSN Patient Care Manager 4 West

Joseph Z., RN, BSN Full patient care, documentation, orders, admissions,
discharges—rooms 410-414
Maria C., RN Full patient care, documentation, orders, admissions,
discharges—rooms 415-417
Joy T., RN, BSN Full patient care, documentation, orders, admissions,
discharges—rooms 418-420
Michael Y., RN Full patient care, documentation, orders, admissions,
discharges—rooms 421 and 422
Clarisa T., RN Full patient care, documentation, orders, admissions,
discharges—rooms 423-425

Reference: https://nursekey.com/patient-care-management-2/
2. Primary Nursing
❖ Primary Nursing in the Inpatient Setting
➢ It is also known as relationship-based nursing.
➢ The primary nurse assumes 24-hour responsibility for planning the care of one or more patients
from admission or the start of treatment to discharge or the treatment’s end.
➢ During work hours, the primary nurse provides total direct care for that patient. When not in
duty, associate nurses follows the care plan established by the primary nurse.
➢ Originally, primary nursing was designed for use in hospitals, but it can lend itself well to home
health nursing, hospice nursing, and other health-care delivery enterprises as well.
➢ Integral responsibility is to establish clear communication among the patient, physician,
associate nurses, and other team members.
➢ Uses some of the concepts of total patient care and brings the RN back to the bedside to provide
clinical care
➢ Holistic, high-quality patient care given through the combination of clear interdisciplinary
group communication and consistent, direct patient’s care by relatively few nursing staff.
2. Primary Nursing
❖ Registered Nurse Primary Care Coordinators in Patient-Centered Medical Homes
➢ The PCMH delivers cost-effective, primary care, utilizing care coordination, ensuring high
value and improving health outcomes.
➢ RNs are increasingly serving as the front line primary care leaders in PCMHs alongside
physicians and advanced practice nurses.
➢ In this role, RNs engage patients and families in care coordination, enhance care transition,
manage complex chronic patient care plans, and promote preventive care services to empower
patient self-care (Baker, 2015).
➢ Unfortunately, neither urban nor rural settings have developed a comprehensive definition of
what RN primary care coordination is, nor is it being implemented in a uniform manner.
➢ Baker (2015) conducted a literature review and conducted interviews with rural primary care
providers to address the problem. Her study findings yielded seven for care management for the
RN primary care coordinator.
The seven domains required for primary care coordination included the following:
1. Population health management: A change from a focus on a single provider caring for the health and well-being of an
individual patient to a focus on a health-care team managing the health of a panel of patients.

2. Comprehensive assessment and care planning: A thorough knowledge of chronic disease management and evidence-
based guidelines and protocols, especially for chronic heart failure (CHF), chronic obstructive pulmonary disorder
(COPD), diabetes, and depression.

3. Interpersonal communication: Includes the ability to use different communication styles, including active listening, to
counsel, interview, resolve conflict, build relationships, and develop effective interdisciplinary teams.

4. Education/coaching: A working knowledge of adult education principles and learning techniques, readiness to change,
and identification of necessary person-centered components for a self-management plan.

5. Health insurance and benefits: Current knowledge of health insurance, managed care, and other payer sources and
benefits.

6. Community resources: A thorough familiarity of public and private community-based providers, services, and support
available in the local geographical area.

7. Research and evaluation: A basic understanding of research and evaluation techniques to assist in quality improvement
of care and interpretation of program outcomes.
2. Primary Nursing
❖ Interprofessional Primary Health-Care Teams
➢ Primary health-care teams (PHCTs) are interprofessional teams that include, but are not limited to, physicians, nurse
practitioners, nurses, physical therapists, occupational therapists, and social workers who work collaboratively to deliver
coordinated patient care.

➢ The desired outcomes for PHCTs are;

■ Reduced mortality and improved quality of life for patients

■ Reduction in health-care costs, and

■ More rewarding professional experience for the health-care worker.

➢ The challenges to implementing primary health care on the PHCT mirror many of the challenges seen in more traditional
primary care, including hurdles in their formation, overcoming the traditional physician dominated hierarchy in
determining who should lead the team, role confusion, and determination of structure and function of the team.

➢ Interprofessional team brings together differing viewpoints, life experiences, and knowledge of evidence-based practices,
determining what knowledge is most important in caring for the patient can be confusing.
 Primary Nursing

ADVANTAGES: DISADVANTAGES

❏ Job satisfaction is high ❏ Difficult degree of responsibility and

❏ More professional system: RN plans autonomy of the primary nurse.
and communicates with all ❏ Difficult to retain and recruit RN to
healthcare members. be PN, especially in times of nursing
❏ RN develops skills and feel shortage.
challenged and rewarded at the same
time.
 Structural Diagram of Primary Nursing
Healthcare
Physician Charge Nurse Organizations
Resources

Primary Nurse

Patient

Associate Nurse Associate Nurse Associate Nurse

(Evenings) (nights) (as needed days)
3. Team Nursing
❖ The Multidisciplinary Team Leader Role
➢ One of the recommendations of the 2010 Institute of Medicine Report, was to expand the
opportunities for nurses to lead and diffuse collaborative improvement efforts with physicians
and other members of the health-care team to improve practice environments
➢ Incorporate pharmacists, social workers, occupational therapists, speech therapists, and other
health-care workers as part of the multidisciplinary team to assure that comprehensive and
holistic health care can be provided to each patient, although the responsibility for team
leadership still often falls to the RN.
➢ Require an efficient means of communication about patient goals, progress, and problem.
➢ Implementation problems are common, however, in multidisciplinary teams, having experts on
teams is different than having expert teams; each discipline may believe that their perspective is
most important and undervalue the contributions of other team members.
3. Team Nursing
● Developed that reduced the fragmented care that accompanied functional nursing.
● Ancillary personnel collaborate in providing care to a group of patients under the direction of a
professional nurse.
● As the team leader, the nurse is responsible for knowing the condition and needs of all the patients
assigned to the team and for planning individual care.
● Team conferences occur in which the expertise of every staff member is used to plan the care.
● The Team Leader has a core of staff reporting to her, and together they work to disseminate the care
activities.
● The team leader’s duties vary depending on the patient’s needs and the workload.
● Duties of team leaders:
○ Assisting team members
○ Giving direct personal care to patients
○ Teaching, and
○ Coordinating patient activities.
 Team Nursing

ADVANTAGES: DISADVANTAGES

❏ Job satisfaction is moderate to high ❏ Requires a team spirit and

depending on the member’s commitment to succeed.
capabilities ❏ RN may be the Team Leader one
❏ Patients have one nurse (the Team day and a team member the next,
Leader) with immediate access to thus continuity of patient care may
other health providers. suffer.
❏ Care is still fragmented with only 8
or 12 hour accountability
Reference:
https://nursingcrib.com/nursing-notes-reviewer/fundamentals-
of-nursing/modalities-of-nursing-care/
Structural Diagram of Team Nursing
Charge Nurse

Team Leader Team Leader

Nursing Staff Nursing Staff

Patient Patient
4. Modular Nursing
● Uses a mini-team (two or three members with at least one member being an RN) with
the members of the modular nursing team sometimes being called care pairs.
● Patient care units are typically divided into modules or districts.
● It is a geographical assignment of patient that encourages continuity of care by
organizing a group of staff to work with a group of patients in the same locale.
 Modular Nursing

ADVANTAGES: DISADVANTAGES

❏ Useful when there are a few Rns ❏ Paraprofessionals do technical

❏ RNs have more time to plan their aspects of nursing care
care

Reference:
https://nursingcrib.com/nursing-notes-reviewer/fundamentals-
of-nursing/modalities-of-nursing-care/
 Structural Diagram of Modular Nursing
Nurse Manager

Geographic Geographic Geographic

Patient Unit Patient Unit Patient Unit

Patient Care Patient Care Patient Care

Team: Team: Team:
● RNs ● RNs ● RNs
● LPNs/LVNs ● LPNs/LVNs ● LPNs/LVNs
● Nurse Aides ● Nurse Aides ● Nurse Aides
- Meds - Meds - Meds
- Supplies - Supplies - Supplies
- Linens - Linens - Linens
5. Functional Nursing
● Is a task-oriented method wherein a particular nursing function is assigned to a
specific member. Work assignments by functions or tasks such as giving medications,
changing of dressings, giving TSB’s, or taking vital signs.
● Assignment by function.
● Advantage is there is no role confusion. You knew what you were doing. This method
is efficient and cheap.
● Disadvantage is the client could not identify who their caretaker was because there
were so many caretakers.
 Functional Nursing

ADVANTAGES: DISADVANTAGES

❏ A very efficient way to delivery care. ❏ Care of patients become fragmented

❏ Could accomplish a lot of tasks in a and depersonalized
small amount of time ❏ Patients do not have one identifiable
❏ Staff members do only what they are nurse
capable of doing ❏ Very narrow scope of practice for
❏ Least costly as fewer RNs are RNs
required ❏ Leads to patient and nurse
❏ No role confusion. dissatisfaction
Reference:
https://nursingcrib.com/nursing-notes-reviewer/fundamentals-
of-nursing/modalities-of-nursing-care/
 Structural Diagram of Functional Nursing

Charge Nurse

LPN/LVN RN RN RN RN

Oral Treatments Intravenous Vital signs Hygiene

medications Admissions medications Supplies

UNIT OF 30
PATIENTS
6. Nursing Case Management
● “A collaborative process of assessment, planning, facilitation, and advocacy for options
and services to meet an individual’s health needs through communication and available
resources to promote quality cost-effective outcomes”. (CMSA)
● Nurses address each patient individually, identifying the most cost-effective providers,
treatments, and care settings possible.
● The case manager helps patients access community resources, helps patients learn about
their medication regimen and treatment plan, and ensures that they have recommended tests
and procedures.
● Often begin in the hospital inpatient setting, with length of stay (LOS) and profit margin
per confinement used as measures of efficiency, but now they frequently extends to
outpatient settings as well
● Acute care case management - integrates utilization management and discharge planning
functions and may be unit based, assigned by patient, disease based, or primary nurse case
managed.
6. Nursing Case Management
● Case managers often manage care using the following to plan patient care:
○ Critical pathways
■ Also called as clinical pathways.
■ A strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care.
■ Reflect relatively standardized predictions of patients’ progress for a specific diagnosis or procedure.
■ Advantage: provide some means of standardizing care for patients with similar diagnoses.
■ Disadvantage: difficulties they pose in accounting for and accepting what are often justifiable
differentiations between unique patients who have deviated from their pathway.
■ Patient progress that differs from the critical pathway prompts a variance analysis.
○ Multidisciplinary action plans (MAPs)
■ a combination of a critical pathway and a nursing care plan.
■ It indicates times when nursing interventions should occur.
■ It facilitate expected outcomes.
6. Nursing Case Management
❖ Disease Management
➢ Also known as population-based health care and continuous health improvement, is a comprehensive,
integrated approach to the care and reimbursement of high-cost, chronic illnesses.
➢ One role that is increasingly assumed by case managers is coordinating disease management (DM)
programs.
➢ The goal of DM is to address such illnesses or conditions with maximum efficiency across treatment
settings regardless of typical reimbursement patterns.
➢ DM programs reduced health-care expenditures for individuals with asthma, cardiovascular disease,
congestive heart failure, depression, musculoskeletal problems, low back pain, and migraines. Also
reduced hospitalizations for those same conditions except for congestive heart failure and reduced
avoidable hospitalizations for individuals with asthma, depression, and low back pain. DM did not have
any effect for individuals with diabetes, arthritis, or 369 osteoporosis.
➢ Focus is on “covered lives” or populations of patients, rather than on the individual patient.
➢ Goal is to service the optimal number of covered lives required to reach operational and economic
efficiency.
Common Features of Disease Management Programs

1. Provide a comprehensive, integrated approach to the care and reimbursement of common, high-cost, chronic
illnesses.

2. Focus on prevention as well as early disease detection and intervention to avoid costly acute episodes but
provide comprehensive care and reimbursement.

3. Target population groups (population based) rather than individuals.

4. Employ a multidisciplinary health-care team, including specialists.

5. Use standardized clinical guidelines—clinical pathways reflecting best practice research to guide providers.

6. Use integrated data management systems to track patient progress across care settings and allow continuous and
ongoing improvement of treatment algorithms.

7. Frequently employ professional nurses in the role of case manager or program coordinator.
 Nursing Case Management

ADVANTAGES: DISADVANTAGES

❏ All professionals equal team ❏ Requires qualifies nurse case

members. manager, team collaboration, and
❏ Members take ownership of patient quality management system.
outcomes ❏ Established critical pathways
needed.

Reference:
https://slideplayer.com/slide/4885415/16/images/28/Case+Ma
nagement+Advantages+Disadvantages.jpg
 Structural Diagram of Case Management Process

Following-Up
Screening Assessing Planning Implementing Transitioning Evaluating
(ongoing)

Satisfying Communicating
Risk Post Transition
7. Innovative / Contemporary Method
New Roles for the Changing Health Care Arena:
Nurse Navigators . Clinical Nurse Leaders . Leaders in Patient Care

● Health care delivery models are continuing to emerge that expand the role of nurses
beyond direct caregivers.

● A white paper entitled Innovative Care Delivery Models: Identifying New Models That
Effectively Leverage Nurses, was published by Health Workforce Solutions in 2008.

❖ This white paper suggested that nurses form the backbone of almost all these new
models and that eight common themes could be identified
among the most successful care delivery.
Common Themes Found Among Newer
Care Delivery Models
1. Elevating the role of nurses and transitioning from caregivers to “care integrators”
2. Taking a team approach to interdisciplinary care
3. Bridging the continuum of care outside of the primary care facility
4. Defining the home as a setting of care
5. Targeting high users of health care, especially older adults
6. Sharpening focus on the patient, including an active engagement of the patient and his
or her family in care planning and delivery, and a greater responsiveness to the patient’s
wants and needs
7. Leveraging technology
8. Improving satisfaction, quality and cost.
 Nurse Navigators
❖ Is a relatively new role for professional nurses.
❖ It help patients and families navigate the complex health care system by providing
information and support.
❖ Acts as a guide, resource, advocate, educator, and liaison for newly diagnosed cancer
patients and their family.
❖ The navigator is the consistent caregiver through the cancer journey, coordinating
appointments and schedules while keeping the patient and family actively involved in
their plan of care.
❖ Nurse Navigation commonly occurs in targeted clinical settings such as oncology,
whereby a breast cancer nurse navigator might work with a woman
from the time she is first diagnosed and then follow her throughout
the course on her illness.
Common Nurse Navigator Roles in Oncology
● Serves as a clinician, care coordinator, educator and counselor for patients and families.
● Help patients and their families understand the diagnosis and treatment plan.
● Improves patient outcomes through education, support and monitoring.
● Coordinates care with other health care providers such as radiologist, pharmacist,
dietitians social workers, case managers and counselors.
● Help the patient and family connect with community resources (working with social
workers with expertise in this area)

● Remain available and in contact with the patient and caregivers throughout the treatment
process; the patient may call at any time day or night with question about medication,
symptoms, lifestyle changes, or other concerns.
 Clinical Nurse Leader
❖ The newer patient care delivery models is include the nurse as clinical expert leading
other members of a team of partners.
❖ The CNL, as an advanced generalist with a master’s degree in nursing, is expected to
provide clinical leadership at the point of care in all health-care settings, implement
outcomes-based practice and quality improvement strategies, engage in clinical
practice, and create and manage microsystems of care that are responsive to the
health-care needs of individuals and families (AACN, 2007).
❖ CNLs have advanced knowledge and education in general practice as opposed to one
primary discipline, like Clinical Nurse Specialist (Johnson & Johnson Services Inc.,
2015).
❖ “Assumes accountability for health-care outcomes for a specific group of clients within
a unit or setting through the assimilation and application of research-based information
to design, implement, and evaluate client plans of care”
❖ The CNL then is a provider and a manager at the point of care to individuals and
cohorts and as such designs, implements, and evaluates client care by coordinating,
delegating, and supervising the care provided by the health-care team (AACN, 2007).
❖ The CNL also plays a key role in collaborating with interdisciplinary teams.

❖ CNL as a leader of these teams identifies risk analysis strategies and resources
needed to ensure the safe delivery of care and then relies on patient-centered,
evidence-based practice and performance data to make needed decisions (RWJ,
2009).
❖ At the Veterans Affairs, CNLs serve as the point person on patient care teams and are
leaders in the health-care delivery system.
❖ “This revolutionary role is providing an increasingly positive impact on patient care
outcomes, and professional career satisfaction for many staff nurses” (U.S. Department
of Veterans Affairs, 2014, para. 3).
 Patient and Family Centered Care

❖ Represent a change in the paradigm of care and strongly influence how care must be
delivered.
❖ An innovative approach to the planning, delivery, and evaluation of health care
grounded in mutually beneficial partnerships between patients, families, and healthcare
providers (Abraham & Moretz, 2012).
❖ The philosophy of patient-centered care is based on the premise that care should be
organized first and foremost around the needs of patients (Planetree, 2014a).
Planetree argues that patient-centered care is the “right thing to do”
❖ Thus, it humanizes, personalizes, and demystifies the patient experience.
❖ An approach to the planning, delivery, and evaluation of health care that is grounded in
mutually beneficial partnerships among health-care providers, patients, and families,
thus redefining the relationships in health care (IPFCC, 2010).
❖ The Institute of Medicine identified patient-centered care as one of six points for health-
care redesign and one way to provide care “that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that patient values
guide all clinical decisions”.
Core Concepts of Patient and Family Centered Care
● Patient care is organized first and foremost around the needs of patients

● Patient and family perspectives are sought out and their choices are honored.

● Health-care providers communicate openly and honestly with patients and families to
empower them to be effective partners in their health-care decision making.

● Patients, families, and health-care providers collaborate regarding facility design and the
implementation of care.

● The voice of the patient and family are represented at both the organizational and policy
levels as well as in the health system’s strategic planning.
According to Warren (2012), the two most prominent pioneers in developing and promoting
patient- and family-centered care:

1. Planetree - a mission based not-for-profit organization that provides partners with healthcare
organizations around the world and across the care continuum to transform how care is
delivered.

Guided by a foundation in 10 components of patient centered care, Planetree;

➢ Informs policy at a national level
➢ Aligns strategies at a system level
➢ Guides implementation of care delivery practices at an organizational level
➢ Facilitates compassionate human interactions at a deeply personal level
2. The IPFCC - a not-for-profit organization offering health-care providers and institutions
information and core guiding concepts related to patient- and family-centered care.
➢ These concepts include:
■ Open visitation
■ Family presence during all procedures
■ Patient, family, and staff communication and collaboration in care plan development,
multidisciplinary rounds, and bedside handoffs between nurses
■ Information availability in patient and family resource centers
■ And the use of patient and family advisors in performance and safety improvement efforts.
■ In addition, the model encourages the use of soft colors, lighting, home-like fabrics, and music
for patient rooms and common areas as well as opportunities for patients and families to learn
about their illness in order to foster participation in their care.
According to Abraham and Moretz (2012);

● Nurses must act as catalysts for initiating and integrating the health-care provider, patient,
and family partnership practices in daily care.
● Agrees that “no matter what one’s nursing role—clinical, educational, administrative—it is
possible to champion patient- and family-centered change so true collaboration with
patients and families becomes embedded in the organizational culture”
● This requires the leadership skills of vision, planned change, team building, and
collaboration.