Policy Manual sample

MDT Home Health Care Agency, Inc. Goals of Care: Independence Transition from role of patient to self-care No ER visits No hospitalizations No unscheduled home care visits When is the Patient Ready to Transition to Self-Care? Within 12-14 visits Stable with goals met Verbalize and demonstrate self-monitoring goals and objectives Verbalizes early exacerbation signs Medication regimen adherence Nurse is no longer needed Home Health Agency Nursing Care & Procedures K-233