A client’s customized home care plan or plan of care is one of the most important tools at the disposal of Assisting Hands caregivers. Its elaboration follows a structured protocol, which starts with a thorough nurse interview with the client and/or family members or legal representatives. It is usually followed up by one or more phone calls to clarify questions that may have been missed during the in-person interview, and it is complemented by a service-site safety evaluation.
Every time a new caregiver is assigned to a client, he or she receives a copy of the plan of care and discusses it with a nurse or case manager. In some complex or delicate cases (such as advanced dementia, severe mobility impairments, autism or post-surgical care), the caregivers undergo complementary training provided by our nurses, which refreshes important case-specific techniques or care aspects that must be observed.
Plans of care are continuously updated, as a consequence of supervisory visits, experience accumulated on the case by our caregivers, and interactions with the client, healthcare professionals or family members. Every update is automatically shared with all caregivers assigned to a client, and case managers follow up with individual aides to ensure adherence to the updates.
There is no “one-size-fits-all” plan of care. In addition to the client-identification section, each plan will contain parts of the following:
- Service calendar and shift structure;
- Names of assigned caregivers;
- Amount of free supervisory visits authorized under the plan;
- List of authorized family members or legal representatives whom caregivers may share in-home service-provision details (legally, no information may be shared with persons who have not been formally authorized by the client);
- List of usual healthcare providers and their contact information;
- List of current medications and their intake regimen (if medication reminders are part of the plan);
- Social and religious activities – if a client actively engages in social or religious activities, the plan of care indicates whether (and when) a caregiver is expected to accompany said client;
- Brief personality and preferences assessment – habits, preferred activities, activities that should not be performed, suggestions of how to engage with the client;
- Complete assessment of client’s mental– and physical-health situation – this section describes from sensorial and speech impairments to mobility issues, from meal-support needs to fall-prevention activities;
- Full list of activities of daily living to be supported by our caregivers;
- Exercise-support guidelines (usually provided by a physiotherapist assisting the same client);
- Calendar of external activities in which Assisting Hands’ support is required (transportation to medical appointments, visits to healthcare facilities, sports activities);
- Nutrition requirements and meal plan;
- List and calendar of light housekeeping needs;
- Dress-code requirements – some families prefer that a caregiver wear scrubs, others request that they do not “look like nurses”.
For more details about our home care plan or intake process , please schedule a visit by one of our nurses.