PA-HCS 5: Care Monitoring
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Routine care
monitoring ensures delivery of appropriate services.
A human service professional:
- conducts a second visit or phone assessment with the service recipient within the first two weeks of service; and
- conducts a re-assessment every 60 days thereafter at a minimum, in person or by phone, if necessary and approved.
Care providers:
- document all interventions and how the person responds;
- monitor and document changes in physical, mental, and emotional status and gains of the individuals and their care givers;
- respect and note service recipient choices;
- help individuals make independent choices or assume more responsibility for making decisions;
- recognize service gaps and emergency situations and follow procedures to ensure the safety and well being of care recipients; and
- report on plan implementation and progress to a supervisor or case manager at least twice a month.
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Research Note: Regarding element b.), family service providers who seek to understand the effects of stress on quality of life, point to the importance of helping caregivers appraise stress associated with the care recipient’s behaviors and needs, and to address sufficiency of resources to meet family demands and needs. A related recommendation when caregiver stress is identified is to determine if families require a plan for managing stress. |
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Research Note: A home care satisfaction measure, developed under the auspices of cooperating interdisciplinary university departments and a research institute, is based on views of older consumers gathered through focus groups. Participants represented a single ethnic group and state, limiting generalizability; however, reported psychometric properties are strong and reported adaptability within other states is promising. Home care satisfaction negatively associated with degree of physical disability is consistent with earlier research that is, as yet, not conclusive. Research and the development of benchmarks against which agencies can compare their performance to national home care satisfaction results is on-going. |
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The care provider and person receiving services, or
legal guardian, regularly review progress toward achievement of
service goals and sign revisions to goals and care plans.
Interpretation: Multidisciplinary team conferences should include the care recipient, direct care providers, family, and other care givers whenever possible.
The worker and a supervisor, or a clinical, service, or peer team review every case quarterly, at a minimum, to assess:
- care plan implementation;
- progress toward achieving goals and desired outcomes; and
- the appropriateness of continuing services and goals.
Interpretation: Experienced managers may conduct care plan reviews of their own cases. In such cases, the manager’s supervisor reviews a sample of reviewed cases consistent with the requirements of the standard.
Timeframes for care plan reviews should be adjusted depending upon issues and needs of individuals receiving services, frequency and intensity of services provided, and frequency of contact with informal caregivers and cooperating providers.
