Salient factors approach starts with assessment
Step-by-step guide to improve care planning process
Connie Burgess, MS, RN, president of Connie Burgess & Associates, a Lakewood, CA, consulting firm that specializes in redesigning health care operations, provided Patient-Focused Care with these assessment tips for more effective care planning.
• Perform initial patient assessment as a team.
Rather than having one person conduct the admission assessment, the salient approach calls for a representative from nursing, as well as physical, occupational, and speech therapy to be present, she says.
Such team assessment allows members to focus on key issues: where the patient is going and what it will take to get there, Burgess adds. "It really fosters professional collaboration," she says. "Staff can share their interpretations of observations and teach one another from their own areas of expertise."
Although the team does need a leader to guide the assessment, no one is specifically designated for that position. "Team members may take turns leading each assessment. The leader asks the demographic questions, and other members ask questions pertaining to their specific discipline," Burgess says.
Say it once, do it right
With team assessment, a provider can eliminate redundancy for both the patient and the health care professionals, she says. "Also, because each team member hears and sees the same thing, there is less room for inconsistent information. If several people assess the patient over a course of time, they may hear one thing at 8 a.m. and another at 3 p.m."
Burgess’ only caveat for team assessment is that it may not be effective for cognitively impaired patients who may be disoriented if four people are in the room. "In the case of a cognitively impaired person, use one or two team members," she advises.
• Consider consequences of the injury or illness, rather than the medical diagnosis alone.
After the initial assessment, team members meet immediately for a "mini-conference" to begin putting together the care plan. But it is not based just on diagnosis. "You must create a specific list of patient focuses that are relevant to each patient," she says.
• Form the right care team for each patient.
"Remember, every patient doesn’t need every team member. I’ve heard this from payers many times: I don’t care if 92 people are on the team. What I want to know is if the right members are on a team,’" Burgess says.
The secret in putting together the right team is the patient’s goals, not the discipline’s goals. "There is a finite amount of benefits to be paid, so eliminate team members that are not relevant," Burgess says. The individualized list of goals, as determined by the assessment team and the patient, drive the type of therapy that will be utilized. One patient may need to focus simply on activities of daily living, while another may need extensive occupational therapy to be able to return to work.
• Expect to share accountability.
Once the care plan is formulated and the list of patient goals is developed, the team focuses on working together to meet those goals.
For example, if a therapist is working with a patient on a bladder training program and that patient needs to void in the middle of therapy, the therapist can help the patient to the toilet using therapeutic transfer and dressing techniques. "In this interdisciplinary model, the patient’s legs and the transfer do not belong to physical therapy and the bladder to the nurse. They all belong to the patient," Burgess says.
• Be consistent.
To reinforce patient and family education, clearly outline each specific intervention so that every member of the team uses the exact same technique.
For example, if a family needs to learn how to transfer a patient in order for him or her to go home, but they are only available to learn that process after 8 p.m., a physical therapist does not have to be there to teach them. "In the interdisciplinary model, the night nurse can assume that job," Burgess says. Other team members also help the patient learn the needed discharge skill by using the same techniques during the rest of the 24 hours.
"This consistency speeds up the learning process because it gives patients more opportunities to learn. It also helps build the patient’s and family members’ confidence because it eliminates confusion as to the right way,’" says Burgess.
• Remember home is a destination, not a discharge plan.
"To put home as the discharge plan only tells where the patient is going, not what they need to do in order to function once there," Burgess says.
To create an effective discharge plan to home, base the plan on facts, not assumptions, she suggests.
"Don’t assume you know what their home is like, based on your belief and values. You must get details of their home in order to create a discharge plan," Burgess says. "Ask questions like: Does it have stairs? Is it in the city or a rural area? Is the entrance handicapped accessible? Who else lives at home?"
• Use documentation as main link between team members.
The documentation system should clearly define, in measurable terms, the long-term goals, short-term goals, and discharge goals, Burgess says. "This enables the staff to know the parameters in which they are working and what is expected," she says.
• Hold morning huddles with team.
A 10-minute meeting held first thing in the morning gives team members a head start on the day, says Burgess. "It reviews anything that happened to the patient both pro or con in the past 16 hours," she says. "But it is a huddle not a care team conference. We only talk about patient changes. If nothing has changed, we don’t talk about it.
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