Review patient’s medical, psychological, and social condition
5
Discussion of patient's goals and expectations
6
Approval: Patient's Goals and Expectations
7
Design individualized care plans based on inputs received
8
Coordinate with medical professional for medication management
9
Discuss and determine the frequency of home visits
10
Application for any needed medical equipment or assistive devices
11
Initiate contact with patient's family or caregivers
12
Approval: Individualized Care Plan
13
Educate patient's family about the care procedure
14
Schedule next IDG meeting
15
Document results of the IDG meeting and decisions made
16
Approval: Meeting Notes and Decisions
17
Communicate decisions made in the meeting to all stakeholders
18
Implementing the approved care plan
19
Monitoring the progression of the plan and patient’s condition
20
Finalize and review progression and updates for next meeting
Schedule initial IDG meeting
Schedule the first interdiscplinary group (IDG) meeting to discuss the patient's care plan and goals. Determine a suitable date and time for all healthcare professionals involved. Ensure that the meeting location is accessible and comfortable for everyone. Consider any potential scheduling conflicts and find a suitable solution.
Prepare patient's clinical summary and record
Compile all relevant medical, psychological, and social information about the patient. Create a comprehensive clinical summary detailing their history, diagnosis, treatments, and any relevant test results. Ensure that the record is accurate, up-to-date, and well-organized.
Invite interdisciplinary healthcare professionals
Invite the necessary interdisciplinary healthcare professionals to attend the IDG meeting. Consider individuals such as physicians, nurses, social workers, chaplains, and volunteers. Discuss the patient's condition and gather their perspectives to create a holistic care plan.
Review patient’s medical, psychological, and social condition
Thoroughly review and assess the patient's medical, psychological, and social condition. Analyze their medical history, current symptoms, and any recent changes. Evaluate their emotional well-being, support system, and living situation. Identify any specific challenges or concerns that need to be addressed.
Discussion of patient's goals and expectations
Engage in a meaningful discussion with the patient to understand their goals and expectations. Ask open-ended questions to explore their desired outcomes, quality of life preferences, and personal values. Foster a supportive and empathetic environment to ensure their comfort and trust.
Approval: Patient's Goals and Expectations
Will be submitted for approval:
Discussion of patient's goals and expectations
Will be submitted
Design individualized care plans based on inputs received
Collaborate with the interdisciplinary team to design individualized care plans based on the patient's inputs and healthcare professionals' expertise. Consider all aspects of care including medical interventions, psychosocial support, symptom management, and spiritual care. Ensure that the plan is comprehensive, achievable, and aligned with the patient's goals.
Coordinate with medical professional for medication management
Collaborate with the patient's primary medical professional to coordinate medication management. Communicate medication schedules, dosage instructions, potential side effects, and any necessary adjustments. Ensure that the patient and their caregivers are well-informed and educated about the medications.
Discuss and determine the frequency of home visits
Discuss and determine the frequency of home visits by healthcare professionals. Consider the patient's needs, available resources, and the interdisciplinary team's recommendations. Explore options for 24/7 support if required. Ensure that the patient's comfort and safety are prioritized while establishing the visit schedule.
1
Once a week
2
Twice a week
3
Three times a week
4
Once a month
5
As needed
Application for any needed medical equipment or assistive devices
Identify and apply for any necessary medical equipment or assistive devices required to support the patient's care plan. Consult with the interdisciplinary team and evaluate the patient's specific needs. Complete the necessary paperwork, submit applications, and follow up to ensure the timely acquisition of the equipment or devices.
Initiate contact with patient's family or caregivers
Initiate contact with the patient's family or caregivers to introduce the hospice services and establish a support system. Provide information about the interdisciplinary team, the care plan, and available resources. Address any concerns or questions that the family or caregivers may have.
Approval: Individualized Care Plan
Will be submitted for approval:
Design individualized care plans based on inputs received
Will be submitted
Educate patient's family about the care procedure
Educate the patient's family or caregivers about the care procedure and their role in supporting the patient. Explain the various aspects of care such as medication management, symptom control, emotional support, and communication strategies. Provide educational resources, manuals, and contact information for further assistance.
Schedule next IDG meeting
Schedule the next interdisciplinary group (IDG) meeting to review the progress of the care plan and discuss any necessary adjustments. Determine a suitable date and time for all healthcare professionals involved. Ensure that the meeting location is accessible and comfortable for everyone. Consider any potential scheduling conflicts and find a suitable solution.
Document results of the IDG meeting and decisions made
Thoroughly document and summarize the results of the interdisciplinary group (IDG) meeting. Record the discussions, decisions made, and any adjustments to the care plan. Ensure that the documentation is accurate, organized, and easily accessible for future reference.
Approval: Meeting Notes and Decisions
Will be submitted for approval:
Document results of the IDG meeting and decisions made
Will be submitted
Communicate decisions made in the meeting to all stakeholders
Effectively communicate the decisions made during the interdisciplinary group (IDG) meeting to all relevant stakeholders. Ensure that healthcare professionals, the patient, and their family or caregivers are informed about any changes, updates, or new instructions. Foster open and transparent communication to maintain a collaborative approach to care.
Implementing the approved care plan
Implement the approved care plan, ensuring that all aspects are executed with attention to detail. Collaborate with the interdisciplinary team to assign responsibilities, establish timelines, and ensure smooth execution. Regularly monitor and evaluate the care plan's implementation to identify any challenges or areas for improvement.
1
Medication management
2
Symptom control
3
Psychosocial support
4
Spiritual care
5
Special dietary needs
Monitoring the progression of the plan and patient’s condition
Regularly monitor the progression of the care plan and the patient's condition. Assess the effectiveness of interventions, evaluate symptom management, and gather feedback from the patient and caregivers. Make necessary adjustments to the care plan based on observations and feedback. Maintain open communication with the interdisciplinary team regarding the patient's progress.
Finalize and review progression and updates for next meeting
Finalize and review the progression and updates of the care plan for the next interdisciplinary group (IDG) meeting. Assess the effectiveness of interventions, discuss any concerns or challenges, and document the recommended adjustments. Ensure that all relevant information and updates are thoroughly reviewed and ready for discussion in the next meeting.
