Every home care patient has their own individualized and customized care plan. The point of a care plan is to develop specific goals to be achieved through the course of care. For some particularly complex or long term clients, multiple care plans may be needed. In these situations the HHA should defer to the Case Supervisor in the coordination of client care. That said, a HHA can remain confident that there will always be one specific, approved care plan to follow. Each provider on the care team (such as a speech therapist or physical therapist) will have their own care plan for a given client.
The overall goal of the care plan is to guide and help the client recieve the best level of health possible through specific actions and attention. If an activity is not contained in the HHA;s care plan, it should NOT be performed without prior authorization from the case manager. There is a great deal of time and thought that goes into a typical care plan. As such it should be followed faithfully and very carefully.
Care planning should always include input from the client and their family to compliment that input from the healthcare professionals on the care team. The healthcare professionals will conduct an assessment of the clients physical, mental, financial and social needs. After the doctor prescribes a course of treatment for the client, the supervisors, case manager and nurses must complete a specific care plan for the client that aligns with the doctors diagnosis and treatment goals. Many factors will be weighed in this process of creating a care plan. These factors could include the client’s health, physical condition, medical diagnosis, additional services required, and the overall state of the client’s family and home.
It is also important to note that care plans must be kept up to date, especially as the clients condition improves or declines. A HHA’s duty ro report these sorts of changes to their case supervisor is essential in making sure the client care plan is kept up to date and optimal for the clients health needs. A communicative and observant HHA will allow a care team to successfully update a care plan to meet a given clients needs.