PURPOSE
To ensure all persons served have their care needs thoroughly assessed upon entry and at regular intervals according to best practice.
To ensure that care provided is appropriately planned in a timely manner to meet the persons served specific needs.
To clarify the roles and responsibilities of each professional and the family / support system involvement.
POLICY
Island Home Health Care develops a care plan in consultation with the persons served / family and support system. The care planning process is based on data and information gathered during assessments which involves the identification of goals, actions or interventions that will resolve or alleviate the persons served problems and/or needs. The persons served / family and support system are encouraged to participate in the care planning process to determine mutually agreed upon goals. Reassessment occurs when there is change of status and care plans are to be reviewed monthly using the Care Plan Form.
DEFINITION
We strive to provide quality care using a personalized care plan developed in consultation with the person served and / or family / caregiver as applicable. The care plan guides the actions and defines the role of the home care professional and family / caregiver /support system.”
CARE PLAN
The care plan is a result of collaboration between the professional healthcare provider and the person served and family / support system.
It is based on an individualized assessment conducted by the healthcare professional.
Addresses the needs, values, and preferences of the person served and family/ support system.
Consistent with the persons served circumstances.
Responsive to changing needs and circumstances and revised when indicated.
Review with the person served and family / support system
The care plan identifies the goals and needed resources
PROCESS
1. Upon admission, clinical staff completes assessments according to their scope of practice and responsibilities.
2. The Initial Assessment must be completed at the first home care visit. The Initial Assessment with initial care plan guides the delivery of care until the long term care plan is achieved.
3. When the persons served status changes (medical, functional or other), the relevant assessment is reviewed and updated as needed and the corresponding care plan is also updated. Notifications of changes to care requirements are updated on the handover sheet and communicated to staff.
4. The family, caregiver and support system are involved as indicated. Skilled services are provided by the respective healthcare professional. Unskilled services should be provided by the family or their support system.
Teaching is an important and integral part of our care. Our healthcare professionals and our approach focuses on empowering the persons served / family and support system to gain as much independence as possible.