H O M E H E A LT H C A R E P L A N I N G P R O C E S S
Farzad Darabi Administrator
July, 2014
Purpose
This in-service addresses DHC policy
At completion each attendant will
Know company policy on care planning
Know the necessary steps for proactive care planning
Know the importance of collaboration with care team members
Learn to use the knowledge gained to improve quality of care
The Process ●
Plan of care
Within 5 days from first admission, or reassessment
All clinicians must contribute to the planning process
Patient and family must take part in planning process
Skilled nursing Care plan by RN
Therapy care plan by Therapist (PT, OT, SPT)
Review and update care plan
Every 60 days Before transfer When patient experiences a significant change in condition When patient is discharged and readmitted during same 60-day episode
Care Plan
Primary and secondary diagnosis
Food and drug allergies
Home bound status
Goals and expected outcomes
Patient mental status
Functional limitations
Permitted activities
Safety measure
Nutritional requirements
Medication and treatments
Specific procedures with frequency and duration
Necessary supplies and equipments
Discharge or referral plans
Discharge teaching
Visit frequency and duration
Rehab potential
Prognosis
Precautions
Contraindications
Care Plan Procedures
When planning consider the following
Individualized patient needs Changes in condition
Drug Monitoring Pain and symptom management Psychological and spiritual needs Patient choices
Care plan is according to physician order
Care plan for therapy is designed by therapists Care plan changes are based on: Assessment
The planning focuses on
Goals
Identifying Patient Problems
Necessary Action
Achievable goals
Clinical notes
Service type, frequency, and duration Actions necessary to meet goals
Equipment and supplies
Prognosis
Verbal orders
Care Plan Procedures Cont.
The physician will be informed of all changes to patient condition
Changes to care plan is approved by physician
Changes are written, signed, and documented by the clinician
Care plan must include needs, desires, abilities, support system, and medication monitoring
Services are personalized and monitored for response to care and for achieving expected outcome
Procedures are based on facts, leading to proper plans
CS will regularly review the care plan for progress and need for change
Physician Participation ●
●
The care of patient is directed by a physician The attending physician certifies that home health care is necessary
●
The physician shall participate in the care planning process
●
The physician will initiate, review, and revise orders for care
●
Physician orders will include:
Diagnosis
Treatment and procedures (type, frequency, duration, and goals)
Medication administered and monitored
Description of equipment and supplies
Precautions, limitations, and permitted activities
Physician Participation ●
●
●
●
Initial certification of Plan of Care is verbal and documented The physician will certify plan of care by signing it within 30 days from SOC The physician must certify the plan of care at least every 60 days from SOC The physician will changes orders based on
Changes in care or service
Changes in patient physical or psychological condition
Patient response to care
Patient’s outcome related to care
Changes in diagnosis or treatment ●
●
●
Recertification orders no sooner than 5 days to recertification date If the attending physician changes, service will stop until new written orders are obtained Only one physician orders care, all others will be informed
Physician Orders
Physician orders are taken by appropriate clinician Document orders on proper from. Read telephone orders back to the physician for accuracy Date, and sign the order
The CS will review orders for care prior to providing care
Only in emergency cases order verification can be delayed
An order can be e-mailed, faxed, or received verbally
Verify orders when There is a question or discrepancy The order was communicated by someone other than the physician
The physician must sign all orders within 30 days Only one copy of each signed order is kept in patient file
Rehabilitative Services Planning
Rehabilitation planning is performed by therapists
Determine patient current functional state
Plan considers diagnosis, age, disease, prognosis, and disability
Encourage participation in rehab planning and implementation
Therapy services will be according to rehabilitation plan
Goals are based on patient expectations
Goals will be revised according to needs
Rehabilitation planning promotes optimal functioning
Managing specific health problem
Maximizing emotional well being according to treatment program
Functioning assessment is integrated into discharge planning
Reassess patient functionality regularly
Discharge planning starts early in treatment program
Discharge planning will consider progress in functionality
Nutritional Planning
Nutritional planning is a part of care planning
DHC does not have a dietician
The assessing clinician will evaluate patient’s nutritional status
The clinician will include special diets in care plan according to physician order
Special diet will be ordered according to care plan
Refer for Nutritional Consultation when
Patient is at nutrition risk
Nutrition care planning is complex
A need for further assessment by a specialist
Educate patient on:
Proper storage of food
Sanitation to prevent spoilage and contamination
Lighting, ventilation, and humidity
Proper and sanitary food preparation
Nutritional Planning, Cont.
Ongoing monitoring
To evaluate patient response to nutrition therapy
To decide appropriateness of choices, regimen, and route
To communicate conclusions to all team members
For discussion at case conferences and discharge planning
To identify inadequate nutrition
To find comfort levels and patient choice
To establish transitioning from oral to enteral or parenteral to enteral
Report problems with nutritional status to:
The CS
The physician
When special prescribed diet
Provide verbal information and training
Provide written material about the diet, purpose, and expected outcome
Competency in administering enteral and parenteral feeding
CHHA Care Plan
Patients in need of Home Health Aide will have a CHHA care plan
Clinician prepares the CHHA care plan according to physician orders
CS will review the CHHA care plan with assigned staff
The CHHA care plan will be revised at least every 60 days or as needed
CS will review change to CHHA care plan with assigned staff
The CS reviews the CHHA care plan with the patient
A current copy of CHHA care plan is kept in patient’s home file
The CS and clinicians will supervise the HHA at least every 14 days
CHHA Care Plan CHHA care plan include Type of service and/or procedure Frequency of visits Relevant diagnosis and/or prognosis Functional limitations Mental status Permitted activities Nutritional needs Specific procedure (type, amount, frequency, and duration) Safety measures and use of equipments Documentation Reporting changes Allergies
CHHA Care Plan Orientation
CS will assign the HHA
When assigning CHHA consider Patient Needs at initial and ongoing assessments HHA competencies Specific needed care
Provide HHA with sufficient written patient information on Physical Psychological, and Environmental conditions as well as patient needs
Patient care instructions Verbal Written Demonstration
CHHA Care Plan Orientation Cont.
Orientation and Monitoring
Schedule an initial placement visit to orient HHA
Complete the HHA assignment sheet and sign (HHA, CS or CM)
Repeat demonstration as needed
Assignment sheet correlates with orders
HHA completes clinical notes and submitted to office
Health problems or changes are noted and reported to the CS
When assigned HHA is changed
Repeat on-site orientation
Complete HHA change form
Document all activities
CHHA care plan and changes
Patient wishes
HHA Assignment
HHA Orientations
HHA Trainings
HHA Changes
HHA Reports
Non-Skilled Care Plan
Patients receiving support/chore (non-skilled home care) services will have a support plan
Assigned staff (NA)will provide service according to plan
The CM will develop the support plan
The support plan include:
Type of service
Schedule of service
Duties, including amount, frequency, and duration
Other pertinent service items
Orientation
Staff
Patient
Sign service plan (CM & NA)
Review and revise support plan at least every 6 months
A copy of support plan kept at patient home file
Supervise NA for adherence to plan and training
Discharge Planning
Discharge planning is a process and starts upon admission
Patient is appropriately prepared before discharge
Continuing care needs are assessed and addressed before discharge
Patient will receive sufficient information to plan for discharge and post-discharge.
At Admission
Identify anticipated date of discharge
Identify available resources (human and finance)
Identify anticipated changes in living situation
Identify areas of need for assistance
Document discharge potential on care plan
Provide information to other team members at the initial case conference
Discharge Planning Cont.
Clinician assistance in discharge
To provide patient and family consultation about the need for discharge
As a referral source to obtain follow-up support
To consult patient on provisions of discharge information
To help patient participate in case conferences about his/her discharge
Communicating post discharge information to physician
The CS will address all issues and problems regarding discharge planning
The entire communication regarding discharge planning is documented
Continuity of Care
Continuity of care is fostered by consistent assignment of personnel
To ensure continuity of care Limit the number of identified personnel assigned to patient care Conduct periodic case conferences regarding progress
Case Manager (CM) Each patient will have an assigned CM, a clinician The CM is responsible for all communication regarding patient care Updating physician orders and obtaining lab results Updating plan of care Communicate changes in orders and findings to team members and CS Liaison between different disciplines, physician, and patient Conduct discharge planning Schedule visits Conduct supervisory visits Create and update CHHA care plan Create and update support plan
Continuity of Care Cont. CS is responsible for patient assignment according to census and needs The CS will consider: Geographic area Needs and required skills Availability of internal resources (skills, education, training, and staff availability) Language and communication needs Acuity of care Clinician caseload Previously assigned personnel Patient’s requests
The CS consults the director or administrator on staffing needs and issues
Case Conferences
Case conferences are for multidisciplinary cases
CM will hold case conference at least every 60 days
All clinicians and direct care staff will participate
Case conferences and participation are recorded
A progress summary is attached to patient record and sent to physician
Discussions include
Patient’s physical status
Implication of diagnosis and treatment
Patient choices
Changes in condition
Interventions
Teaching plans and effectiveness
Progress
Indications for recertification
Discharge planning
Coordination with other Vendors
CM is responsible for coordinating and communicating services by other providers
CM is the liaison with other organizations or individuals including
Address personnel understanding of organizational responsibility
Initiation of communication when there is significant change to patient condition
Monitoring conflicts and duplication and possible resolution
Document all referral to other providers
Other providers must obtain their own orders for evaluation and treatment
Address issues to the CS
Ultimately DHC management holds the final responsibility for other vendor relations and breakdown in communication
Internal Referral Process
Internal referral to other disciplines will be documented in patient file
The CM will contact the physician to obtain order for additional services
A completed referral form will be given to CS for assignment
The assigned clinician will obtain orders from physician for evaluation and treatment
Questions
FOR YOUR PARTICIPATION