Planning Care in the Community

1. Planning Care in the Community Stake Holders: Clients, their Families and Carers The Glamorgan Spring Bay Community Nursing Service team members. Elaine Hosken - Clinical Nurse Educator - Professional development. The Spring Bay Community and Health Centre. The Department of Health and Human Services. The Glamorgan Spring Bay Community Nursing Team. Where it started Client Centered Care Planning Objectives The Concern Index What does the literature say? Outcomes Potential for validation as a tool for the documentation of the plan of care. An opportunity for multi-service/disciplinary care planning with scope to be used as a discharge planning tool within acute settings. Team members have increased their knowledge base in the areas of practice development, documentation, research, person-centred care and Principles of Primary Health Care. Developed team members ability for critical and reflective practice, resulting in a number of other safety and quality projects being initiated Works Cited Vic Health endorses the Registered Nurses Association of Ontario (RNAO) Best Practice Guideline for Client Centred Care. It does not provide a tool for the documentation of care plans stating ‘documentation tools will need to be adapted to reflect the client population and the care setting (RNAO, 2006).’ There is evidence within the literature which demonstrates the value in effective care planning, however, the process of documenting and communicating the plan lacks specificity, particularly in relation to the community setting (Keenen et al, 2008). This is supported by a number of papers evidencing the effects of inadequately recorded care planning on clinical outcomes (Griffiths & Hutchings 1999, Yocum 2002, From et al, 2003). • We needed a care planning tool that: • Involved the client, family and carers in decisions about their care. • Provided effective, continuing care and communication without repetition. • Fulfilledprofessional and legal documentation requirements. • Fulfilled regulatory/accreditation standards. • Was simple to use. The Glamorgan Spring Bay Community Nursing team met in November 2011 with Clinical Nurse Educator, Elaine Hosken, to discuss client centeredness and how we currently form care plans. We needed a care planning tool which was suitable for use within the context of community nursing. The ‘Concern Index’ replaces the traditional community nursing ‘Care Plan’ and provides an index of care, similar to the index of a book. It is an innovative development of an holistic care planning tool for the community setting. The document is designed to designate an identifying number to each concern and track the page number and date on which the concern is reviewed. The concern reviews are conducted at predetermined intervals with the client, family and carer using the SOAP documentation format (subjective, objective, assessment and plan). A SOAP includes the client’s thoughts, feelings and ideas regarding each aspect of their care along with measurable information, assessment and continuing plan of care. This enables clients to be in control of their health care decisions. An approach to care that consciously adopts the individual’s perspective... (World Health Organisation, 2004). Assess Plan Physical psychological spiritual Community Location Context Family Friends Culture Beliefs Values Likes & Dislikes Evaluate Implement From G, Pederson M, Hansen J, et al 2003, Evaluating two different methods of documenting care plans in medical records. Clinical Governance: An International Journal, vol.8. issue. 2, pp. 138–50 Keenan GM, Yakel E, Tschannen D, Mandeville M . (2008). Documentation and the Nurse Care Planning Process. In: Hughes RG Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockwell: Healthcare Research and Quality. Registered Nurses Association of Ontario (RNAO), 2006, Nursing Best Practice Guideline for Client Centred Care, viewed at www.health.vic.gov.au/.../02PersonCentredPractice/.../Client%20Centred Yocum R, 2002, Documenting for quality patient care, Nursing, vol 32, issue 8, pp 58–63. Claire Warren, 2013.