Orientation: Care Planning

1. Care Planning Defined

Developing an effective care plan is an essential element in the provision of services to the home care patient. Incorporating an interdisciplinary, holistic approach fosters successful patient outcomes. This chapter will define what is meant by the term "care plan," discuss the impact of the patient and family inclusion in this process, and examine the important function this process plays in care delivery. An introduction to the steps of the care planning process will be provided.

2. The Care Planning Process: The Comprehensive Assessment

The comprehensive assessment begins the care planning process. The clinician's knowledge and use of specialized assessment skills in collecting data plays an integral role in the success of the care planning process. This chapter will identify the elements of a holistic comprehensive assessment per the Medicare Conditions of Participation and discuss the skill set required to effectively perform the assessment.

3. The Care Planning Process: Problem Identification

The accuracy of problem identification and prioritization impacts the effectiveness of the plan of care and your patient's achievement of care outcomes. Actual and potential problems relevant to the home health episode are identified based on the comprehensive assessment. This chapter will discuss how to identify relevant patient problems and prioritize them to support successful goal attainment.

4. The Care Planning Process: Identifying Patient-Centered Goals/Outcomes and Interventions

The planning process includes two elements: the development of patient-centered goals/outcomes and the identification of interventions to support successful goal attainment. This chapter will discuss the structure of how home care goals/outcomes are written and the very important role of patient and caregiver involvement in actual goal development. The process for determining appropriate interventions to support goal attainment will be discussed from a regulatory and reimbursement perspective. The responsibility of the home care clinician to communicate the plan of care to the patient/caregiver will also be discussed.

5. The Care Planning Process: Implementation

Effective interdisciplinary care requires communication, collaboration, and coordination. These elements are essential in the care delivery process. This chapter will discuss these key concepts and provide strategies for efficient and effective care delivery.

6. The Care Planning Process: Evaluation

The flexibility of the care planning process allows for evaluation of the effectiveness at any point in the process. This chapter will examine what aspects are evaluated, the process to perform an evaluation, and what to do when the plan is not working.