Program Service Delivery
Develop a Client Care Plan and Case Management
The client care plan is developed by the Home Care Nurse
Coordinator with the client and informal care giver based on the
needs identified during the client assessment process.
The purpose of the care plan is to document the health and/or
functional needs/problems, the goals of care, how long the
service is planned for, what the client and supports will do,
what home care will do and what referrals are necessary.
The care plan will also document any allergies, medications,
treatments, special diet or special precautions that are specific
to the client. Sample care plans are available in Handbook 4.
The goals for care should be clearly stated, realistic, understood
and agreed upon by the client, the family/informal care giver
and the health and/or social service care provider. The goals of
care should be supported by identifying and assigning the
necessary tasks and services, when, how often and for how
long the tasks will be carried out.
Example Goal
To teach client to administer insulin injections safely and as
ordered and to understand the signs and symptoms of diabetic
reactions.
Example Task
R.N. will visit daily and instruct client regarding signs and
symptoms of diabetic reactions until client is able to explain
them and will teach client to administer insulin, rotating and
recording sites and will observe client doing self-administration
until proficiency is achieved.
Example Goal
To teach client/informal care giver to change wound dressing,
using clean technique.
Example Task
R.N. to cleanse left lower leg ulcer with normal saline and apply
dry dressing daily until client/informal care giver demonstrates
ability to do so then will continue to monitor progress weekly
until healed.
In some communities, there may be standard definitions of
care, e.g. cleaning may mean sweeping/washing floors,
cleaning bathroom, wiping counters and removing garbage.
Assist with a.m. care may mean assisting client to get dressed,
wash, brush teeth and prepare breakfast. If these standard
definitions are used, it saves time in doing assignments but it
must be remembered that any deviation from
these definitions has to be clearly stated such
as cleaning and changing bed or assist with
a.m. care and assist client with range of
motion exercises.
The care plan is
dynamic and will
be updated frequently
as the care needs are
met or as the client's
condition, treatments or
medications change.
The care plan should be
readily available to anyone
providing services.
When developing the care plan goals and tasks, you may want
to use the opportunity to once again review the Program's
Mission Statement, Philosophy and relevant policies and
procedures with the client, family member/informal care giver
and home care staff to ensure that expectations of services to
be provided are clearly understood. For example:
Client - Inform client that staff will only do assigned tasks.
If changes are needed or wanted, the client is asked to
contact the Home Care Nurse Coordinator. Staff will
encourage and work with client to learn ways to become
independent or remain as independent as possible.
Informal care giver - Review informal care giver's
responsibilities to ensure these are clearly understood.
If responsibilities cannot be met, the informal care giver
should arrange to have someone else provide the service or
call the Home Care Nurse Coordinator to make alternate
arrangements so that the client's care needs continue to be
met.
Home Care staff - Review program policies and procedures
relevant to the goals of care so these are clearly
understood. Review other key policies and procedures
related to the delivery of service on a regular basis (refer to
Policies Template Manual for examples). For example:
- Confidentiality;
- Ethics and Employee Conduct (these will address
important issues such as hand washing, e.g. with an
approved solution or with soap and water, and when
not to provide care as assigned, e.g. if client is not
home or if there appears to be a risk to staff safety).
Collecting Client Data
To fully understand and be able to meet client care needs,
client data must be collected from a variety of sources and kept
on a client file. For reasons of confidentiality, it is recommended
that policies be developed around access to and safe keeping
of client files (refer to Policies Template Manual for examples).
Client data includes:
Relevant Orders
All medication and treatment services must be accompanied by
current, signed Physician's orders or other designated health
care professionals (as approved by the health care system in
each community). It is recommended that each community
develop a policy stating the frequency of updating these orders
as well as the accepted form, e.g. faxed copy, phone orders.
Discharge Summaries
When clients are discharged from facilities such as hospitals, it
is necessary to have the following information in order to
provide appropriate services:
- reason for admission;
- treatment/medication while in facility;
- physical/functional changes that have occurred as a
result of current hospitalization;
- required treatments/medications to be continued at
home;
- follow up appointments; and
- relevant orders for treatments/medications and
medical supplies/equipment.
Transfer Reports
If a client is transferred back to the community from another
program it is necessary to have the following information:
- services that were received;
- supports from informal care givers;
- reasons for transfer;
- current treatments/medications;
- current illnesses;
- current abilities; and
- contact person from transferring agency/program.
Case Management
Case management is a key element to managed care.
Managed care is widely understood to mean the right care is
provided by qualified and competent health team members
at the right frequency and duration that will best support that
person. It can be said that managed care goes beyond First
Nations and Inuit home and community care services (with
client consent) to link with other care and service providers
outside the community. The goal of case management is to
coordinate the multiple services a client may be receiving to
ensure quality and consistency of those services regardless of
who or what agency provides the care.
The Home Care Nurse Coordinator usually assumes the role
of Case Manager. Case management can be achieved by
establishing Health and Social Service Team meetings or
multidisciplinary team meetings to ensure that the appropriate
linkages and referrals have been made, and by holding care
(case) conferences to determine the best ways of meeting
client care needs, involving staff and/or the family
as appropriate.
Multidisciplinary team meetings are an important way to
manage client care. For this reason, it is recommended that
team meetings be held on a regular or as needed basis in order
to review services provided to clients and avoid duplication.
Team meetings can also be used to carry out anticipatory
planning on program issues that may arise (e.g. elder abuse).
The composition of the team will vary by community but
generally includes the Home Care Nurse Coordinator,
Community Health Nurse, Social Services Director/Manager,
Home Health Aide and the Community Health Representative.
If a community has children with special needs requiring
home care services, it will be important to ensure Child and
Family Services staff are part of the team. Ultimately what is
important is that:
- client care needs are met in a coordinated and
comprehensive manner;
- relevant community agency staff involved with client
care participate (this will help avoid one program off
loading onto another); and
- client confidentiality be strictly adhered to during
these meetings.
Because client information will be shared at the multidisciplinary
team meetings, it is recommended that
community members not participate on this committee.
A more appropriate way of involving community members
and elders in the Program may be to establish a Community
Member Advisory Committee who would meet regularly to:
- bring community concerns to the attention of the
multidisciplinary team;
- receive information regarding policy changes and/or
revisions; and
- advise the Health and Social Services Team about
community reaction to new programs or new
directions.
Care/Case Conferences are different from multidisciplinary
team meetings and should also be held on a regular or as
needed basis. These sessions may involve staff providing home
and community care services only or can include family
members as well (family conferences). The goal of these
sessions is again to support client care needs. Front line staff,
who often work in isolation, are important contributors at these
meetings and should be encouraged to attend and participate.
One way to encourage attendance is to make the meetings part
of the front line worker's schedule of work. The Home Care
Nurse Coordinator is likely the most appropriate person to chair
the meetings if she is responsible for all care planning,
coordinating and direction/supervision of staff.
Service Referrals will make sure that the client can pass from
one health or social service to another without difficulty, and
the information from one service will follow the client to the
next service. Examples of service referrals may be:
- from one home care agency to another if the client
moves;
- from one program to another if service needs change,
e.g. from home care to mental health program; and
- consultation with specialist services such as those
offered by a Diabetes Education Specialist.
It may be necessary to contact outside agencies/programs
to inform them of new programs in your community.
Communication and a good rapport with other agencies/
programs and an understanding between programs and
agencies will improve referrals and linkages. Providing program
and/or cultural awareness information will also improve chances
of better uninterrupted/coordinated care for clients since
outside agencies need to know:
- who to contact;
- what services are available; and
- how to arrange implementation of care or
continuation of services.
Examples of referrals from outside services that may be
required to support the community based activities and client
needs include:
- experts in wound management;
- rehabilitation services;
- pharmacists; and
- nursing procedure experts.
All referrals should be written, dated and signed. The client
must be aware and consent to all referrals. If a Consent to
Treatment and Sharing of Information form is used, the client's
signature is required. The Home Care Nurse Coordinator should
ensure that the client understands and agrees to the referral.
Linkages with other programs and services are also important
to establish. It is recommended that linkages be formalized in
the form of written agreements between programs and/or
between communities when linkages/referrals have been made.
These agreements should clearly state what, when, how and by
whom shared services will be provided.
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