Policy Manual sample

MDT Home Health Care Agency, Inc. MANAGEMENT OF PATIENT WITH CONGESTED HEART FAILURE (CHF) POLICY: Facilitate the Nurse approach to care patient with CHF in the home care environment. CHF is a complex clinical syndrome that is frequently, but not exclusively, characterised by objective evidence of an underlying structural abnormality or cardiac dysfunction that impairs the ability of the left ventricle (LV) to fill with or eject blood, particularly during physical activity. Symptoms of CHF (e.g. dyspnoea and fatigue) can occur at rest or during physical activity. Home care for elderly patients with CHF decreased hospital admissions and health care costs. Case Manager Responsibilities: • To identify resources and networks required to establish or maintain multidisciplinary CHF care to meet community needs. • To ensure that existing structured CHF programs are aligned with recommended best practice for the home care environment. • To compare existing structured CHF programs with recommended best practice. • To evaluate program delivery using the key performance indicators. Principles of multidisciplinary CHF care: • Multidisciplinary approach (involving Nurses, Care Mangers, Occupational therapists, Physiotherapists, Physicians, Patient’s, Family, Social Workers) • Evidence-based treatment • Early detection of exacerbations, monitoring of signs and symptoms to enable early identification of decompensation and/or deterioration, and effective protocols for symptom management. • Patient-centered approach • Self-care • Continuity of care • Continuous quality improvement • Inclusion of patients and their families in negotiating the aims and goals of care Procedure to help reach better treatment outcomes: • Development and implementation of individualized management plans, following Physician Care Plan. • Promotion of and support for self-care (e.g. taking medicines, following lifestyle management advice about smoking cessation, physical activity and exercise programs, nutrition and limiting alcohol use, and monitoring and interpreting symptoms37) as appropriate to patients’ needs, capacities and preferences. • The use of behavioral strategies to support patients in modifying risk factors and adhering to their management plans • Monitoring of program outcomes and systems to ensure continuous quality improvement. • Social worker empowering communities programs to engage in selfcare and decision making, and reducing the • stigma of living with a chronic condition. • Providing information and educational materials to patients and home care staff and supporting self-care (as appropriate to the individual’s capacity and preferences) Assessment and documentation: • Assess patients’ capacity for self-care: e.g. formal assessment of patient ability to self-care, health literacy, cognitive function, screening for depression, mood/affect. (ensure understanding of the causes and consequences of CHF, purpose of medicines, medicines to avoid) Home Health Agency Nursing Care & Procedures K-229