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How can you ensure your patients' care plans are updated and revised as needed?

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As a case manager, you are responsible for developing, implementing, and evaluating your patients' care plans. Care plans are dynamic documents that reflect your patients' needs, goals, preferences, and resources. They also guide your care coordination and transition planning activities. How can you ensure your patients' care plans are updated and revised as needed? Here are some tips to help you maintain and improve your care planning process.

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1 Review care plans regularly

You should review your patients' care plans at least every six months, or more often if there are changes in their condition, situation, or preferences. You can use various tools and methods to monitor your patients' progress, such as assessments, surveys, interviews, observations, and feedback. You should also communicate with your patients and their caregivers, as well as other members of the care team, to get their input and opinions. Reviewing care plans regularly can help you identify any gaps, barriers, or opportunities for improvement.

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Rogério Silicani Ribeiro

Gest?o de Saúde Populacional / Inova??o
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Patient centric care. O envolvimento do paciente e do cuidador é fundamental, principalmente entre os portadores de condi??o cr?nica que já tem uma rotina de autocuidado. Os profissionais da linha de frente mudam todo o plant?o mas o paciente e seu cuidador seguem juntos a evolu??o. Eles podem perceber uma melhora ou piora e contribuir com feedbacks para atualiza??o e revis?o do plano de cuidado. Por isto, é importante ouvir sempre!

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2 Revise care plans as needed

Based on your review, you should revise your patients' care plans as needed. You should update the information, goals, interventions, and outcomes of the care plan to reflect the current situation and needs of your patients. You should also document the reasons for the revisions and the expected results. You should involve your patients and their caregivers in the revision process, as well as other members of the care team. Revising care plans as needed can help you adapt to changing circumstances and ensure the quality and continuity of care.

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3 Educate and empower your patients

One of the key aspects of care planning is to educate and empower your patients to participate in their own care. You should provide your patients and their caregivers with clear and relevant information about their condition, treatment options, and resources. You should also encourage them to ask questions, express their preferences, and share their concerns. You should respect their values, beliefs, and goals, and support their decision making. Educating and empowering your patients can help you build trust and rapport, and enhance their satisfaction and adherence.

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4 Collaborate and coordinate with others

Another key aspect of care planning is to collaborate and coordinate with other members of the care team, such as physicians, nurses, social workers, therapists, pharmacists, and community partners. You should establish and maintain effective communication and information sharing among all the stakeholders involved in your patients' care. You should also align and integrate the care plan with other plans, such as discharge plans, transition plans, or advance care plans. Collaborating and coordinating with others can help you optimize the use of resources, avoid duplication or fragmentation of care, and improve outcomes.

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Janet Oliver

consultant
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In an RCFE our mandate is to observe our residents and communicate any change of condition to others to assure the change is addressed ,assuming a resident maintains their independence. It might mean adding outside resources to assist in the process. A revised care plan and new LIC602A is required.

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5 Evaluate and document the results

The final step of care planning is to evaluate and document the results of the care plan implementation. You should measure and track the outcomes of the care plan, such as clinical indicators, functional status, quality of life, satisfaction, and cost-effectiveness. You should also analyze and report the data, and identify any strengths, weaknesses, or areas for improvement. You should document the results of the evaluation in a clear and concise manner, and share them with your patients and their caregivers, as well as other members of the care team. Evaluating and documenting the results can help you demonstrate the value and impact of your care planning process, and inform future actions.

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6 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Tenssie Ramsay, MS, NCC, LPC

Licensed Professional Counselor/Board member Great Oaks | Advisory committee member Bridgeport hospital/ Notary Public.
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In my experience as a provider I utilize a system that sends me reminders to update treatment plans. On the treatment plan review day I remind client of his/ her initial goals and objectives and together with client ascertain the clients progress in treatment.

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How can you ensure your patients' care plans are updated and revised as needed?

1

2

3

4

5

6

1 Review care plans regularly

2 Revise care plans as needed

3 Educate and empower your patients

4 Collaborate and coordinate with others

5 Evaluate and document the results

6 Here’s what else to consider

Case Management

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How can you ensure your patients' care plans are updated and revised as needed?

1

2

3

4

5

6

1 Review care plans regularly

2 Revise care plans as needed

3 Educate and empower your patients

4 Collaborate and coordinate with others

5 Evaluate and document the results

6 Here’s what else to consider

Case Management

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