PA-HCS 4: Assessment Based Care Planning and Coordination
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Individuals and
caregivers participate in a comprehensive, individualized, strengths-based,
family-focused
assessment as the basis for a care plan that specifies the coordinated services needed to promote independent functioning at home and in the community.
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Research Note: An extensive research program beginning in 1993 has been advancing a common language for assessing health and care needs for individuals receiving home care. The result is the Home Care (HC) assessment system. The HC highlights issues related to functioning and quality of life for community residents, and now consists of a Minimum Data Set (MDS-HC). Some item responses “trigger” additional assessment using specific protocols. Multiple trials in several countries have established inter-rater reliability. The MDS-HC can be used at admission and is valuable at 90 re-assessment. Other reported functions include care planning, eligibility screening, case mix, outcome measurement and quality indicator efforts. |
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To ensure an appropriate level of care, the agency completes, or receives from a referring source:
- a current, comprehensive individualized assessment, including the individual’s view of his or her current health and functioning;
- baseline functional, mental, emotional, and physical status information, including prescription medication use and recent or progressive functioning to confirm capacity, decline, or progress;
- a record of fluctuations in functioning and health status re-assessment;
- a caregiver assessment including level of caregiver burden, caregiver health, choice in serving in the caregiver role, and presence of informal support;
- a plan delineating specific services to be delivered by the care provider; and
- a plan for coordinating services with other providers including nurses, physicians, rehabilitative personnel, or mental health providers, as needed.
Interpretation: All service providers, including those who may not have responsibility for the comprehensive assessment and determination of appropriate level of care, should obtain, at a minimum, information regarding an individual's and/or family's
special needs.
Note: Refer to the
Assessment Matrix for additional assessment criteria. The elements of the matrix can be tailored according to the needs of specific individuals or service design.
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Research Note: Resources are now available that provide broad assessment parameters and recommendations for this population. Professional literature recommends standardized instruments selected to assess function should be efficient to administer, easy to interpret, able to provide useful practical information for clinicians, and part of routine history taking and daily assessments. |
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Research Note: The significance of the caregiver’s role, positive and negative effects of assuming a caregiver’s role, and personal and financial benefits to a person receiving services, and caregiver, are the subject of a growing number of studies. The reported mitigating effect of caregiver education and support, resulting in nursing home placement delay and reduction of costs, has prompted the development of caregiver education and support best practice models. |
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The individual or a
legal guardian is the primary source of information about the need for service.
Interpretation: Additional sources of information should be sought to confirm or enhance assessments as appropriate, for example, physical and occupational therapy services may be involved to determine how to manage or prevent further decline.
The information gathered for assessments is directed at concerns identified in initial screenings and is limited to material pertinent for meeting service requests and
objectives.
Personnel who conduct assessments are qualified by
training, skill, and experience, and can recognize individuals and families with special needs.
Assessments are completed within timeframes established by the agency.
Assessments are conducted in a culturally responsive manner and identify resources to increase service participation and success.
Interpretation: Culturally responsive assessments can include geographic location, language of choice, and the person’s religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, and developmental level.
Health and/or social service professionals:
- develop the care plan in cooperation with consumers and care team;
- link interventions to service recipient goals;
- assess service appropriateness;
- approve service plans prior to implementation; and
- assist the care provider with plan implementation, as necessary.
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Research Note: A state study of predictors of use and composition of home care services using case record review data, delivered through Medicaid waiver programs to poor and frail elder people in two large urban counties, has found that much variance in prescription of services remained unexplained. This finding suggests the need for better documentation in the case record and study of the active role the consumer plays in negotiating a final care plan, including preferences and attitudes that can affect decision making. The study also concludes that additional work is needed to understand expected outcomes for various services and service packages, beginning with each client’s level of service. |
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Prior to beginning service, the individual meets with professional personnel and caregivers in the home to review:
- the role of family members in caretaking and related needs;
- any current concerns, including household and community safety;
- specific services to be provided by the care provider;
- limits of services provided;
- preferences and choices of service recipients that can affect service delivery;
- coordination of services with other providers, as appropriate;
- client rights and responsibilities, including how to report complaints or concerns;
- information about advanced directives, and crisis planning as appropriate; and
- guidelines for resolving differences between service recipient and care providers, including the role of supervisors.
Written guidelines that address issues unique to in-home care and service delivery include:
- off-site supervision;
- safety of personnel;
- timely communication and record keeping;
- logging of medications, as appropriate; and
- other prescribed health and safety related procedures.
