Policy Manual sample

MDT Home Health Care Agency, Inc. • Develop personalized action plans and provide clear instructions to patients and caregivers: e.g. daily weight monitoring and recording in personal diary, personalized actions to take when weight or symptoms change. • Assessment and documentation of psychosocial factors: Determine individual needs e.g. apply validated tool to assess concurrent depression, social support needs and carer’s coping • Develop and document plan to personalize care to the patient’s cultural and linguistic preferences and abilities • e.g. referral to psychologists, involve healthcare interpreters and bilingual health workers, arrange support for caregivers. • Negotiate goals of treatment and care with patient and caregivers e.g. routine discussion and offering of advance care plan, regular reassessment and documentation of palliative care options. • Assessment of the patient’s symptoms (e.g. dyspnoea and fatigue). • Assessment of the patient’s functional status, level of fatigue • Physical examination of the patient (at each visit), with particular attention to assessment of their vital signs, cardiovascular system (including volume status), signs of deterioration and comorbid conditions, presence of cough, mucous membrane color, jugular venous distention (JVD), edema measurements ankles/girth/wrists/knee. • Assessment and management of the patient’s cardiovascular risk factors (e.g. hypertension, dyslipidaemia, diabetes, smoking and obesity). • Assessment for reversible causes of CHF (e.g. myocardial ischaemia and anaemia). • Assessment of the patient’s nutritional status. • Assessment of issues associated with ageing and frailty (e.g. risk of falls, vision or hearing impairment, and incontinence). • Monitoring and follow-up of the patient’s existing devices. • Assessment of the patient’s peak oxygen demand – volume of oxygen consumed per minute at maximal exercise (VO2 max). Assess pulse oximetry. • Assessment of the patient’s potential for adverse effects of medicines. • Assessment and documentation of the patient’s renal function and tailoring of fluid, salt restriction accordingly. • Verify if ordered anticoagulation therapy and monitoring of clotting time for patients with atrial fibrillation. • Arrangement of patient participation in self-management programs for specific comorbid conditions (e.g. diabetes and COPD). • Implementation of evidence-based treatment guidelines and monitoring patient adherence to prescribed medicines: Aims: To ensure patients receive evidence-based medicines. To avoid complications due to medicines that may worsen CHF or interactions between medicines. Ongoing monitoring and evaluation of patient’s medicines regimen (both prescription and non- prescription medicines, including complementary medicines), and checking for medicines that may worsen CHF, such as nonsteroidal anti-inflammatory drugs (NSAID), and potential interactions between medicines. Reconciliation with Patient’s Physician. Monitor flexible diuretic regimens, intravenous diuretic administration, where appropriate and ordered by patient’s Physician. Taking Heart Failure History • S&S exacerbation • Activity Home Health Agency Nursing Care & Procedures K-230