Readdressing the Care Plan for CCM 0 Building Leaders – Transforming Hospitals – Improving Care
Faith M Jones, MSN, RN, NEA-BC Director of Care Coordination and Lean Consulting Faith Jones began her healthcare career in the US Navy over 30 years ago. She has worked in a variety of roles in clinical practice, education, management, administration, consulting, and healthcare compliance. Her knowledge and experience spans various settings including ambulance, clinics, hospitals, home care, and long term care. In her leadership roles she has been responsible for operational leadership for all clinical functions including multiple nursing specialties, pharmacy, laboratory, imaging, nutrition, therapies, as well as administrative functions related to quality management, case management, medical staff credentialing, staff education, and corporate compliance. She currently implements care coordination programs focusing on the Medicare population and teaches care coordination concepts nationally. She also holds a Green Belt in Healthcare and is a Certified Lean Instructor. Cynthia DuBois, BSN, RN C3 Solutions, LLC, Principal Cyndi DuBois began her nursing career in Pennsylvania over 25 years ago in a large teaching hospital as an adult intensive care and shock trauma nurse. She then transitioned into home health care as a field nurse and progressed to the director of nursing position where she achieved the initial Joint Commission Accreditation for the agency. Her next step was 2000 miles away when she and her husband relocated to Forsyth, MT, his hometown. She began as a staff nurse at Rosebud Health Care Center then transferred to the Family Practice Clinic in Forsyth as a clinic nurse. She continued to work at Rosebud Health Care Center for eighteen years and had responsibilities in care transitions and discharge planning. She is certified in advance care planning and as a Lean Instructor. Currently, she practices as an independent contractor, fulfilling roles in case management, utilization review, chronic care management, annual wellness visits and advance care planning. . 1
Care Plan for CCM Care Planning for CCM -Using what we have to help the patient set goals -Looking beyond traditional nursing intervention -Documenting, Evaluating and Sharing the care plan 2
Care plan for CCM Moving Forward Readdress the Care Plan to: 1. Determine with the patient, what is important for their care plan 2. Evaluate, Document and Share the care plan (transparency) 3. Keep the care plan alive! It is a dynamic, living document (meaning it can, does, and should change) 3
CARE PLAN FOR CCM Assessment What does the patient say is important? Diagnosis Evaluations: What does the patient Is the patients outcome met? identify as the problem ? Implementation Planning Collaborative interventions to What are the patients meet outcomes priorities and desired Encouragement from HC team outcomes. on each encounter 4
CARE PLANNING FOR CCM Assessment Evaluations Diagnosis Interventions Planning 5
CARE PLAN FOR CCM Person Assessment Defined as referring to the recipient of nursing Who is the recipient of care? actions, who may be an individual, a family, a • Patient community, or a particular group. • Family Unit Who contributes? • Social Network • Friends • Family 6
CARE PLAN FOR CCM Health Assessment Defined as the wellness and/or illness Explore the patient’s definition of state of the recipient. what is most important to them and what they would consider the best health they can achieve Activities Sleep Nutrition Key Events 7
CARE PLAN FOR CCM In Care Coordination is it not about doing everything for the patient, rather we are doing it with the patient. 8
CARE PLANNING – PLANNING BMJ 2010;340:c1900 doi: 10.1136/bmj.c1900 9
CARE PLANNING – INTERVENTIONS It really does take a village Patient Family Community Resources Healthcare personnel Care Coordinator Primary Care Provider Referrals – etc. 10
Care Plan for CCM DOCUMENTATION AND SHARING Now it is time to put the care plan in writing for the patient and the rest of the health care team. This can be as simple as a piece of paper with a goal or two and an intervention or two. This gets copied for the patient and is part of the medical record. 11
CARE PLAN FORMAT 12
Care Planning for CCM Your Logo Care Plan for: Patient Name: Date: Chronic Conditions: 1. Chronic Obstructive Pulmonary Disease (COPD) 2. Congestive Heart Failure (CHF) Agreed Upon Goal(s): 1. Walk dog around the block Interventions: 1.Take Lasix as directed until next visit with the Mr. Ruff PA-C 2.Call the high school to ask for assistance from FCCLA If you have any questions regarding this care plan, please contact our Care Coordinator, ______________ at __________________. 13
EVALUATION OF CCM CARE PLAN Care Coordinator Calls The Patient: Care Coordinator-“Hello, Mrs. Jones. This is Cyndi your Care Coordinator. I was calling to see how your breathing is doing since we talked about having you take your water pill as instructed? CCM Patient- “You know, taking my medication every day has really helped. I am able to cook dinner, eat and do the dishes without feeling like I am gasping for air, my scale says I am down 5 pounds, and I am able to go outside and take a few steps with Heather, the high school student who is helping me make sure my dog is walked”. Care Coordinator-“That is great news! I will let Mr. Ruff your Physician Assistant know! I did not realize you were having difficulties cooking? Would you like me to give you some information for home delivery of meals or are you feeling well enough to prepare all of your meals? CCM Patient-“Oh yes, that would be fantastic. One of my friends was talking about a food delivery truck that brings her meals. Do you have any information on that?” Care Coordinator “I sure do, here it is.” CCM Patient- “Oh thank you!” In Care Coordination it is not about doing for, but rather doing with! 14
15 My Phone Email / Website Faith Jones, MSN, RN My Location (307) 272-2207 Faith.Jones@HealthTechS3.com 476 North Douglas Street Director of Care Coordination Cyndi DuBois www.HealthTechS3.com Powell, Wyoming 82435 & Lean Consulting Services (406) 351-1733 c3solutions@rangeweb.net C3Solutions, Forsyth MT Cyndi DuBois, BSN, RN
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