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Designed for the Unique Needs
of Homecare Providers
This site provides homecare clinicians with access to chronic care management models, best practices and downloadable resources for homecare patients.
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"The body of knowledge that serves as the rationale for nursing practice determines the areas of specialty to develop as well as the manner in which that knowledge is organized, tested and applied." -Carper, 1978
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level 2
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Heart Failure
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Nutrition
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Plan
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| The plan of care includes measurable patient specific goals that are realistic and obtainable. It needs to include buy-in and understanding on the part of the patient and caregiver taking into consideration culture, ethnicity, tradition, individual preferences and economic circumstances. |
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Based on deficits found in the assessment, the plan must be comprehensive, patient
specific and may be multidisciplinary.
Characteristics of a good plan
- Includes a defined time frame
- Developed with the patient and reflects what the patient wants to achieve
Includes a problem list that drives the patient centered goals
- Considers patient’s readiness to change.
- Considers patient’s risks for re-admission
- Outlines the support they need to make changes.
- Includes individualized interventions to meet patient’s goals*
*Under implement category you will find
tools to help you carry out patient goals
Important considerations
- Weight within 3 lbs in 3 days
- If diabetic, target goal for A1C
- Establish target values and alarm parameters for blood pressure to report to primary provider (See OASIS M2200 Plan of Care Synopsis)
- Target values for lipid and lipoprotein levels
- Absence of or adequate treatment of anemia
- Adequate nutrition in presence of depression
- Adequate caloric intake
- Adequate hydration with appropriate use of diuretics
- Adherence to 2 gram to 3 gram Na diet
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Levels of evidence
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Level 1
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Systematic reviews and repeated studies, thoroughly researched.
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Level 2
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Experimental (Single or Quasi experimental study) and non-experimental (Exploratory or qualitative study).
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Level 3
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Recommendations of respected, experienced homecare authorities.
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Level 4
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Not Recommended.
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