Comprehensive Care Plan Development and Implementation

Comprehensive Care Plan Development and Implementation

• The comprehensive Care Plan is a collaborative plan including the client, his or her significant others, decision makers for the client, as well as the treating clinicians. The underpinning of the Care Plan is the Initial Assessment coupled with the desires and objective of the client and the family. From this information, a Care Plan will be developed that outlines specific goals that the client would like to achieve, what the CHC Services care team will do to assist in achieving the goals, and also identifies how frequently re-assessments will occur. These re-assessments help in determining when the goals have been achieved and can help the client and the family plan proactively in deciding what the next steps will be if there is a decline in the client's level of functioning.

Implementation of the Care Plan by the Care Specialist staff

• The team of Care Specialists are primarily responsible for the day-to-day implementation of the Care Plan with the client. They will provide the one-on-one care, coaching and assistance in the activities around the home, in the community and during recreation and pastimes. CHC Services has a very strong emphasis on training of the Care Specialist staff and they are a part of the team comprising the Care Manager, Medical Director, and licensed clinicians.

Comprehensive reassessment of client's care needs, level of functioning and safety in the home

• Completed on a monthly or as needed basis to determine whether improvement, stabilization, or deterioration is occurring with the Client. At a minimum, re-evaluation reports are produced on a monthly basis and are shared with the Client support community which may include family, client's primary physician, and healthcare proxy. These evaluations also serve to determine the level and extent of care that CHC Services staff provides. If the Client's level of functioning is such that he or she is no longer safe in the home setting, our program will work with the Client, family, and healthcare proxy to assure that the next level of care is coordinated and initiated. The CHC Services care manager will continue to coordinate services until the Client is successfully stabilized in the new setting.

Technology assessment and implementation of monitoring and alerting tools

• An assessment will be completed to determine if specific monitoring technologies would be useful to assure physiologic stability and safety in the home. Based on this assessment and concurrence with the client, his or her family or healthcare proxy, different monitoring tools may be implemented.

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