Policy Manual sample

MDT Home Health Care Agency, Inc. • Development of strategies to reduce risk of complications common among older patients (e.g. falls, decubitus ulcers and delirium). • Assessment of the patient’s daily activities and interventions or referral as needed (e.g. referral to an occupational therapist, an exercise physiologist or a physiotherapist). • Provision of advice on sleep hygiene as required. Education and counseling about CHF and its management Provision of clear and reliable information for patients and caregivers on CHF causes, symptoms, exacerbating factors and management (medical and lifestyle). • To provide educational information, resources and advice on self-care, commensurate with the patient’s cognitive function, health literacy, and social, cultural, physical and psychological resources. • Assessment of the patient’s and their carer’s health literacy and cognitive function, using valid and reliable instruments. • Education and counseling for the patient and their carer on CHF and the medicines used to manage it. • Education and counseling for the patient and their carer on lifestyle management. • Education and counseling for the patient and their carer on management of fluid balance, if ordered. • Education and counseling for the patient and their carer about implantable cardioverter defibrillators and left-ventricular assist devices, if applicable, including monitoring requirements • Provision of written information, educational material, pamphlets, that is clear and easy to read for the patient and their carer. • Referral of patient to community-based support groups as appropriate. • Checking that the patient and their carer have understood the information provided (including medicines list and care plan) and agree to the recommended management plan and are involved in its application. • Education of patient’s with home oxygen therapy, including use and safety. Possible Performance Indicators: Continuous quality-improvement activity is increasingly undertaken within home health services and is consistent with Agency’s Policies and Industry Standards. Performance measures/outcomes: Diuresing/Weight: Response to diuretic Meds (Lab work), Lung sounds/Edema, Understand Disease/Tx, response teaching/educational goals, D/C instructions/level understanding. Weight control / total diuretic patients. Respiratory problems response / total Patients admitted Total Patients in whom medicine adherence has been assessed. Total Patients immunized against pneumonia/influenza Total Patients for whom all relevant lifestyle risk factors (e.g. smoking, poor nutrition, salt intake, risky alcohol use, physical inactivity, unhealthy body weight) have been assessed and recorded Total Patients with a personalized management plan that includes medical management and lifestyle risk factor management Total Patients with a personalized exercise program, therapy services Total Patients in whom self-care ability has been assessed Patients in whom cognitive function has been assessed Patients who have been screened for depression Outcome measures (%) Unplanned hospital admissions Deaths Improvement in Disease Management, self care Home Health Agency Nursing Care & Procedures K-232