presented by Tina Marrelli & Kim Corral
The ability to perform an accurate comprehensive assessment and develop an individualized plan of care for home care patients is the foundation for care delivery in home care. This course will review the steps of the care planning process, a type of problem solving method. A discussion will be provided regarding the application of this process and the value it brings to patient care.
Tina Marrelli is the President of Marrelli and Associates, Inc., a publishing and consulting firm working in home care for more than 30 years. Tina is the author of 13 books, including the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement, (6th edition, 2018). Other books include A Guide for Caregiving: What’s Next? Planning for Safety, Quality, and Compassionate Care for Your Loved One and Yourself (2017), Hospice and Palliative Care Handbook (3rd edition, 2018), The Nurse Manager’s Survival Guide (4th edition, 2018), and the best-selling home health aide educational system, Home Health Aide Guidelines for Care: A Handbook for Care Giving at Home and its accompanying Nurse Instructor Manual. Tina served on the workgroups that defined the first hospice nurse standards as well as serving as a reviewer in 2014 for the revised Home Health Nursing: Scope and Standards of Practice through the American Nurses Association. Tina attended Duke University, where she received her undergraduate degree in nursing. She also has master’s degrees in health administration and in nursing. Tina has worked in hospitals, nursing homes, and public health and has practiced as a visiting nurse or manager in home care and hospice for more than 20 years. Tina also worked at Medicare’s central office (CMS) for four years on Medicare Part A home care and hospice policies and operations as well as serving as the Interim Branch Chief for Medicare Part B. Tina loves policy and the nuances that frame care, practice, and delivery. Tina is an international health care consultant, specializing in home care and models of care provided in the community to people at home. Tina and her team of specialized consultants have been in business since 2002 and provide services related to the “design and implementation of challenges to providing home and community-based care.” In that capacity, they have served over 100 clients throughout the world, clients who represent varying segments of service to home care and/or related products. Services include custom presentations, software development, educational services, serving as Team Leader with a team that served as quality monitors to the OIG, accreditation services, new organizational start-ups, due diligence, feasibility studies, and more. Tina has been the editor of three peer-reviewed publications, most recently for Home Healthcare Nurse (now Home Healthcare Now), on which she served as the Editor-in-Chief for eight years. She is also an Emeritus Editor for Home Healthcare Now. In addition, Tina serves on the editorial boards of the Journal of Community Health Nursing and The American Nurse. Tina is the Chief Clinical Officer for e-Caregiving, www.e-Caregiving.com, a web-based support and educational system for family and friend caregivers created to support advocacy and improve care across the health care continuum.
Kim is a registered nurse with a master's degree in Education and over 30 years of home health experience. She is an experienced leader in home health care, having held both clinical and operational positions at regional and national levels for large corporate home health organizations. She brings a passion for providing the clinical voice of quality, while increasing efficiencies. She has extensive experience speaking for state home care associations, national home care organizations, and local home care organizations on regulatory compliance, successful strategies for clinical/operational success, OASIS data collection and strategies, quality outcome improvement, developing successful QAPI programs, documentation standards, and operational processes to support OASIS and ICD-10 accuracy.
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.
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.
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.
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.
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.
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.