Policy Manual sample

MDT Home Health Care Agency, Inc. 174 INTERDISCIPLINARY CARE PLANNING POLICY: • The plan of care is developed and documented by the Registered Nurse, Registered Therapist and/or Social Worker, in coordination with the patient/family/significant other. • The plan of care is communicated to the Case Manager/Clinical Supervisor and other members of the healthcare team. • When a patient is receiving more than one service, each discipline develops interventions and goals that are complementary to those of other team members providing care, treatment and/or services. PURPOSE: • To facilitate appropriate communication, coordination and continuity of care and to promote positive patient outcomes when MDT Home Health Care Agency, Inc. provides more than one service, whether those services are provided directly or through written agreement. • To clearly outline each professional’s responsibilities to avoid duplication of care, treatment and/or services. • To promote awareness among all professionals involved in patient care, including those providing contracted services, of the patient’s needs and goals, and care, treatment or services and interventions to be provided by each individual. PROCEDURE: • Each discipline, i.e., nursing, therapies, social work, including contracted services, contributes to the plan of care, based on the assessment of patient needs and clinical status at the time of the initial/admission visit. • The Case Manager/Clinical Supervisor receives a verbal summary of the plan of care the day of the initial/assessment visit. • The signed original plan of care is submitted to the Agency office within 72 hours of the initial visit. A copy of the plan of care remains in the patient’s home. • The Case Manager/Clinical Supervisor is responsible for overseeing the care planning process. The plan is appropriate and realistic based on the patient’s needs and clinical status, and promotes positive outcomes and avoids duplication of services. • In the event of potential or actual duplication of services, the Case Manager/Clinical Supervisor contacts the disciplines involved and conducts a care conference to correct the