Many people know how wise it is to put money away for retirement. Many people understand the wisdom behind having a will and making sure there is a “back up plan” to take care of any family members that might be affected by our death or incapacitation. However, many patients do not have a home health care plan, and that is a huge mistake.
A home health care plan is just as crucial as a will. It lays out the care you or your family member needs, when they need it, and for how long they will need the care. It is flexible and changeable as circumstances change, and is custom-designed for each individual patients’ needs. Without it, there will be no guidelines or means of monitoring or managing care, and something is bound to be neglected.
Basically, your plan of care is made up of “written doctors orders for home health services and treatments” (Medicare.gov) which are personalized to each patient. “Care planning provides a ‘road map’ of sorts, to guide all who are involved with a patient[’s care]…. To be effective and comprehensive, the care planning process must involve all disciplines that are involved in the care of this patient/resident” (Careplans.com).
There are several steps to developing a home health care plan.
Step #1 – Assessment – This is a full medical assessment done by a family doctor or other medical specialist, and/or by a nurse. At this stage, a patient’s abilities and limitations are assessed and the effects on the patient’s quality of life evaluated.
Step #2 – Problem List – Once the medical assessment has been done, each problem discovered or discussed needs to be written down along with the impact of each problem on the patient’s life. At this stage, the main consideration is “Will this problem get better?” or “Will intervention help this problem get better?” If the answer is “yes” in both these scenarios, a goal will be set, including a timeline and “due date” for reassessment of this particular issue. The goal and interventions needed to achieve that goal should be measurable and realistic. If the answer to the above questions is “no”, specific and measurable goal statements also need to be documented, but focus should turn to maintaining quality of life. This includes medications, and treatments such as physiotherapy or chemotherapy.
Step #3 – Implementation and Adaptation – Once each aspect of a patient’s life has been assessed and a goal for improvement or management--including specific medications or treatments--has been documented, then the plan must be put into practice by the home health care service agency and staff member. This includes any members of the family who may also be involved in providing care or help. “The care plan needs to be fluid and changeable…. Periodic scheduled reevaluation must take place, with changes being made as needed. Unscheduled updates should also be made as condition warrants” (Careplans.com). A review of the plan of care is usually done at least once every 60 days. This cycle will continue until the patient is discharged from care, or passes on.
“Remember that the ultimate purpose of the care plan is to guide all who are involved in the care of this person to provide the appropriate treatment in order to ensure the optimal outcome during his/her stay in [a] healthcare setting. A caregiver unfamiliar with the patient…should be able to find all the information needed to care for this person in the care plan” (Careplan.com).
Sources: Medicare.gov (http://www.medicare.gov/homehealthcompare/(S(hefybrivamfbt345d5qnwuur))/About/GettingCare/PlanofCare.aspx); Careplans.com (http://www.careplans.com/pages/about.aspx)
Edited by Alison Stanton