|
All calls are
handled by specially trained intake person. Once a
referral
has been initiated, you can be to receive services as little
as 24- 48 hours.
Our agency uses
standard HCFA -485/487 forms for physician certification and
re-certification.
Use our online
referral form to refer a loved-one now!
 |
Steps
in developing the plan of care |
The plan of
care
 |
A plan of
care is implemented for each referral. |
|
The
original physician orders are documented |
|
The
patient is assigned a Clinical Manager |
|
The
Clinical Manager compiles a teaching packet and
medication cards based on client diagnosis and physician
orders |
|
The
client is scheduled for admission by a team nurse |
|
The nurse
completes a client assessment on the first visits |
|
The nurse
develops a plan of care consistent with client/family
needs and then confers with the physician regarding the
needed services and frequency of visits based on the
home environment and the client's condition |
|
The
Medicare Form 485 is generated from the physician and
nurse's collaborative efforts. This form functions
as both the plan of care and letter medical necessity |
 |
What's
included in the plan of care? |
Each client's
plan of care will include (as appropriate):
|
A
description of medical condition and need for home
health care |
|
The
results of the assessment |
|
Long and
short-term goals of treatment and expected outcomes |
|
A plan
for individual team members activities |
|
A care
plan for the family caregivers |
|
A list of
medical equipment and supplies |
|
A
hospital to home discharge plan |
|
A
hospital to home discharge plan |
 |
What
assessments are performed? |
Basic assessment includes:
|
Functional assessments |
|
Activities of daily
living |
|
Instrumental
activities of daily living |
|
Sensory assessment |
|
Mental/cognitive
assessment |
|
Psychosocial
assessment |
|
Nutritional assessment |
|
Medication used and
compliance |
|
Family caregiver
assessment |
|
Environmental
assessment |
|
Community assessment |
|
Financial assessment |
|
