Developing a compliant plan of care must be a priority for hospice organizations. The plan of care should address recent compliance trends, including:
- Individualized plan of care
- Hospice aide services
- Registered nurse (RN) designation
- Bereavement
In a session at the 2023 Axxess Growth, Innovation and Leadership Experience (AGILE), Zaundra Ellis, Vice President of Hospice Professional Services at Axxess, and Dr. Jennifer Kennedy, EdD, MA, BSN, RN, CHC, Vice President of Quality, Standards, and Compliance at CHAP, discussed effective processes of hospice care planning and how to implement them to develop a patient-centric hospice plan of care.
Developing the Plan of Care
The individualized plan of care starts in the first few moments of meeting the patient and their loved ones. It continues to develop as the admission assessments are completed. Ongoing assessments during the care process enable the plan of care to continuously evolve to reflect the patient’s wishes and their changing care needs. When creating an assessment, Kennedy says providers should think about what matters to the patient to help develop a meaningful plan of care.
“The assessment drives the care plan process,” Kennedy said. “It’s a back-and-forth cycling situation. It’s a continuous quality situation.”
Effective Processes of Care Planning
Kennedy broke down the following processes of care planning:
- Critical Thinking: Consider how to make the care plan meaningful to the patient and the patient’s family and how to help them develop goals.
- Problem Solving: Find a way to engage the patient and family to give them the confidence they need to make decisions.
- Decision-making: The patient and their family should have quality outcomes. “We want them to have the best death experience they can possibly have,” Kennedy said. “We want to give them comfort, we have to give them dignity and we want to meet what matters for them.”
Know Your Patients
“Knowing your patient is a time investment; that’s a personal investment,” Ellis said. Kennedy encouraged clinicians to go into the visit with open ears and give the patient the time they need to connect and build trust.
“Sometimes we overlook capturing the patient’s voice,” Kennedy said. “In the rare occasion where they can’t speak for themselves, use their caregiver’s voice in developing the plan of care.”
Finding the patient’s voice is important. When the patient is involved, it is easier to document whether they agree or disagree with the plan of care and adjust accordingly.
Plan of Care Alignment
Ellis and Kennedy discussed the following considerations to ensure the plan of care is aligned with the patient’s goals and needs.
- Matters: Find out what matters to the patient.
- Medication: On days when the patient is doing something that is important to them, make sure their medication does not prevent them from doing that task.
- Mentation: Ensure that the patient has not had any changes in their medical history or medications.
- Mobility: Does the patient have mobility issues?
“Look at all of the items, connect those dots and develop the best individualized plan of care,” Kennedy said.
“To get to a good plan of care is taking that next step, asking the next question and continuing evaluation and those relationships that we build,” Ellis concluded.
With more than 250 attendees, more than 40 sponsors and countless connections made, AGILE 2023 was a massive success for everyone. Check out the recap video and mark your calendar for AGILE 2024, April 21-24 in Dallas.
