Debbie Goings

How to write a well-written care plan in home health and hospice

How to write a well-written care plan

Staffing shortages in home health and hospice can lead to incomplete or inaccurate care plans due to limited resources and time. With less staff available, crucial aspects of a patient’s condition may be overlooked or under-addressed, which can result in errors or omissions in the patient care plan. Ultimately, this can keep patients from meeting their goals, reduce or delay reimbursements and cause more work for already overburdened staff.

In this blog, we explore the anatomy of a well-written care plan, why it supports patient-centered care, and how MatrixCare simplifies the process.

What is a care plan?

A well-crafted care plan in home health and hospice is a comprehensive and individualized roadmap that outlines the specific treatments and support services needed to address the patients’ needs while receiving care at home. The patient care plan directly addresses the needs of the patient, family or caregiver and enables staff to provide the best services and environment for patients and families to meet their goals while receiving home health or hospice.

Patient care plans are working documents and need to be flexible based on patient progress or incidences. This approach helps to ensure patient-centered care is a priority.

What are the must-haves of a well-written care plan?

  1. Guide care and provide a roadmap for the patient.

A well-crafted care plan establishes individualized goals and objectives where staff can measure the effectiveness of care and record evidence that the physician’s orders were followed. Moreover, by outlining specific interventions, treatments, and support services tailored to individual needs, it ensures consistency and continuity of care delivery.

This approach guarantees consistent care and also motivates patients to participate in their own recovery process, which can lead to better outcomes and improved patient satisfaction.

  1. Show collaboration across disciplines.

Seamless communication between disciplines is critical to patient-centered care. The care plan helps to ensure patients will receive quality care regardless of which staff members provide it. This is important to consider, as agencies often have staff cover for each other during sick days or vacation.

Ultimately, a well-structured care plan promotes synergy among diverse disciplines, enriching the patient’s journey toward comfort, dignity, and wellbeing.

  1. Justify and support the need for services.

In home health and hospice, a patient care plan is not just a roadmap for treatment; it is justification for the essentiality of services. By documenting the patient’s clinical condition, functional limitations, and care requirements, the plan establishes a clear rationale for the services. It outlines measurable goals and identifies specific interventions tailored to the patient’s needs, emphasizing the necessity of care.

  1. Identify the skilled interventions needed for the patient.

Clinicians should be able to determine what exactly needs to be done based on the care plan.

  1. Include patient, caregiver, and family participation.

A comprehensive care plan in home health should prioritize patient, caregiver and family participation to ensure personalized and effective care. By actively involving them in the decision-making process, the plan becomes more patient-centered and responsive to individual needs and preferences.

Patient and family input helps identify goals, preferences, and challenges, fostering a sense of ownership and empowerment in the care journey. Moreover, their insights provide valuable context for caregivers, enhancing understanding and empathy.

Through regular communication and collaboration, the care plan becomes a shared roadmap, promoting trust, cooperation, and ultimately, better health outcomes for the patient within the comfort of their home.

How does MatrixCare support a well-written care plan?

MatrixCare offers a robust library of interventions and goals, as well as the ability to create agency-defined care plans.

Clinicians document in the patient care plan based on their assessment. If the clinician documents in the visit note something that is not part of the care plan, MatrixCare will make suggestions for new interventions.

More benefits of a MatrixCare-supported care plan include:

  • Historical information at your fingertips
  • Designed to help meet regulatory requirements
  • Speech-enabled documentation at the point of care
  • Secure, real-time messaging with care teams, partners, patients, and family caregivers
  • Ready access to nationwide networks allowing bi-directional clinical information

Ready to take your care plans to the next level? Connect with us today and we’ll show you how.

See what MatrixCare can do for you

Debbie Goings

With 25 years in nursing and 15 years in post-acute care, Debbie Goings understands the pain points faced by providers and those they employ. From working for a large home health agency as a case manager, coder, OASIS specialist and Director of Compliance, to being a home health and hospice surveyor and legal nurse consultant, Debbie has experienced every angle of this industry. Her experience has fostered her passion for staff to have more time to care and interact with the patient and family — all while maintaining compliance with an EMR that will provide the clinician the ability to maintain requirements.

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