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Readdressing the Care Plan for CCM
Building Leaders – Transforming Hospitals – Improving Care
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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 herleadership 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. Shecurrently implements care coordination programs focusing on the Medicare population and teaches care coordination concepts nationally. She also holds a Green Belt inHealthcare 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 healthcare 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 whenshe 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 clinicnurse. 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 planningand as a Lean Instructor. Currently, she practices as an independent contractor, fulfilling roles in case management, utilization review, chronic care management, annual wellness visits andadvance care planning.
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Care Plan for CCM
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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
Care plan for CCM Moving Forward
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Readdress the Care Plan to:1. Determine with the patient, what is important for their care plan2. 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)
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CARE PLAN FOR CCM
AssessmentWhat does the patient
say is important?
DiagnosisWhat does the patient identify as the problem?
PlanningWhat are the patients priorities and desired
outcomes.
ImplementationCollaborative interventions to
meet outcomesEncouragement from HC team
on each encounter
Evaluations: Is the patients outcome met?
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CARE PLANNING FOR CCM
Assessment
Diagnosis
PlanningInterventions
Evaluations
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CARE PLAN FOR CCM
Person Defined as referring to the recipient of nursing actions, who may be an individual, a family, a community, or a particular group.
Assessment Who is the recipient of care?• Patient• Family UnitWho contributes?• Social Network• Friends• Family
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CARE PLAN FOR CCM
Health Defined as the wellness and/or illness state of the recipient.
AssessmentExplore the patient’s definition of what is most important to them and what they would consider the best health they can achieve
Activities
Sleep
Nutrition
Key Events
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CARE PLAN FOR CCM
In Care Coordination is it not about doing everything for the patient, rather we are doing it with the patient.
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CARE PLANNING – PLANNING
BMJ 2010;340:c1900doi: 10.1136/bmj.c1900
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CARE PLANNING – INTERVENTIONS
It really does take a village Patient Family Community Resources Healthcare personnel Care Coordinator Primary Care Provider Referrals – etc.
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DOCUMENTATION AND SHARINGNow 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.
Care Plan for CCM
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CARE PLAN FORMAT
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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-C2.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 __________________.
Care Planning for CCM
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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!
Faith Jones, MSN, RNDirector of Care Coordination & Lean Consulting ServicesCyndi DuBois, BSN, RN
My Location 476 North Douglas StreetPowell, Wyoming 82435C3Solutions, Forsyth MT
My Phone(307) 272-2207Cyndi DuBois
(406) 351-1733
Email / [email protected]
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