Communication with the patient and caregiver about the care plan
9
Establish access to required medications and treatments
10
Setup home visit schedule
11
Assign a case manager for regular follow-ups
12
Coordination with mental health professionals if required
13
Discuss DNR (Do Not Resuscitate) orders if appropriate
14
Arrange for necessary medical equipment at home
15
Approval: Medical Equipment by Nurse
16
Provide resources about coping and bereavement support
17
Review and update care plan as and when necessary
18
Routine monitoring of patient’s condition
19
Approval: Care Plan Updates by Physician
20
Emergency care planning
Initial patient referral for palliative care
This task involves making the initial referral for palliative care. It plays a crucial role in starting the care process for the patient. The desired result is to ensure that the patient is connected to the palliative care program. The task requires gathering necessary information about the patient, their medical condition, and any existing care providers. Some potential challenges could include incomplete referral information or difficulty reaching the patient's primary care physician. Required resources for this task include a referral form and contact information for the patient's primary care physician.
Patient medical history review
In this task, the patient's medical history is reviewed. This helps the palliative care team to understand the patient's health background and make appropriate care decisions. The task has a significant impact on the overall care plan. The desired result is to have a comprehensive understanding of the patient's medical history. The task requires accessing the patient's medical records and identifying any significant health issues. Potential challenges could include incomplete or unavailable medical records. Required resources for this task include access to the patient's medical records system and a review form.
1
Epic
2
Cerner
3
Allscripts
4
MEDITECH
5
Other
1
Diabetes
2
Hypertension
3
Cancer
4
Heart Disease
5
Respiratory Conditions
Identify patient’s primary caregiver
This task focuses on identifying the primary caregiver for the patient. The primary caregiver plays a crucial role in the palliative care process, providing support and assistance to the patient. The desired result is to have a designated primary caregiver. The task requires gathering information about potential caregivers and assessing their availability and willingness to take on the role. Potential challenges could include difficulty reaching potential caregivers or reluctance to take on the responsibility. Required resources for this task include a caregiver assessment form and contact information for potential caregivers.
Physical assessment of the patient
In this task, a physical assessment of the patient is conducted. The physical assessment helps to evaluate the patient's overall health and identify any immediate care needs. This task has a direct impact on the development of the patient's care plan. The desired result is to have a comprehensive understanding of the patient's physical status. The task requires performing a physical examination, documenting findings, and monitoring vital signs. Potential challenges could include patient discomfort during the assessment or difficulty obtaining accurate vital signs. Required resources for this task include a physical assessment form and necessary medical equipment (such as a stethoscope and thermometer).
Conduct pain assessment
In this task, a pain assessment is conducted for the patient. Pain assessment is crucial in palliative care to ensure the patient's comfort and well-being. The task directly impacts the patient's care plan by identifying pain management needs. The desired result is to have a comprehensive understanding of the patient's pain levels and associated factors. The task requires assessing pain intensity, location, and impact on daily activities. Potential challenges could include patient communication difficulties or cultural considerations in expressing pain. Required resources for this task include a pain assessment scale and a pain management plan template.
1
Numeric Rating Scale
2
Visual Analog Scale
3
Verbal Descriptor Scale
4
Wong-Baker FACES Pain Rating Scale
5
FLACC Scale
1
Physical Activity
2
Emotional State
3
Sleep Patterns
4
Environmental Factors
5
Medication Effects
Development of individual care plan
This task involves the development of an individual care plan for the patient. The care plan outlines the specific goals, interventions, and desired outcomes for the patient's care. It plays a central role in guiding the palliative care team's actions. The desired result is to have a comprehensive and personalized care plan for the patient. The task requires assessing the patient's overall condition, identifying specific care needs, and developing appropriate interventions. Potential challenges could include conflicting goals among the care team or limited resources for certain interventions. Required resources for this task include a care plan template and access to relevant guidelines or protocols.
1
General Care Plan Template
2
Pain Management Care Plan Template
3
Symptom Management Care Plan Template
4
End-of-Life Care Plan Template
5
Psychosocial Support Care Plan Template
Approval: Care Plan by Physician
Will be submitted for approval:
Development of individual care plan
Will be submitted
Communication with the patient and caregiver about the care plan
In this task, communication about the care plan is conducted with the patient and their caregiver. Effective communication is vital to ensure that the patient and caregiver understand and actively participate in the care plan. The task has a direct impact on the patient's overall care experience. The desired result is to have clear and shared understanding of the care plan between the care team, patient, and caregiver. The task requires effective communication skills, active listening, and clear documentation of the care plan discussion. Potential challenges could include language barriers, emotional reactions, or conflicting expectations. Required resources for this task include a care plan discussion guide and communication aids (such as visual materials or interpreters).
1
English
2
Spanish
3
Chinese
4
French
5
Other
1
Visual Materials
2
Educational Handouts
3
Translator Services
4
Cultural Brochures
5
Patient Decision Guides
Establish access to required medications and treatments
This task focuses on establishing access to the required medications and treatments for the patient. Ensuring timely access to necessary medications and treatments is crucial in palliative care. The task has a direct impact on the patient's symptom management and overall well-being. The desired result is to have a plan in place for obtaining and administering medications and treatments. The task requires working with the appropriate healthcare providers, pharmacies, and insurance companies. Potential challenges could include medication shortages, insurance coverage issues, or complex treatment regimens. Required resources for this task include a medication and treatment access form and contact information for healthcare providers and pharmacies.
Setup home visit schedule
In this task, a home visit schedule is set up for the patient. Home visits provide essential care and support to patients in palliative care. The task plays a critical role in ensuring that the patient's needs are met in their home environment. The desired result is to have a well-planned schedule for home visits. The task requires coordination with the patient, caregiver, and the healthcare team. Potential challenges could include scheduling conflicts, transportation issues, or safety concerns. Required resources for this task include a home visit schedule template and contact information for the patient and caregiver.
Assign a case manager for regular follow-ups
This task involves assigning a case manager for regular follow-ups with the patient. The case manager plays a vital role in coordinating and monitoring the patient's care. The task has a direct impact on the patient's overall care experience and continuity. The desired result is to have a designated case manager for the patient. The task requires identifying a healthcare provider or team member for the case management role. Potential challenges could include workload constraints or difficulties reaching the assigned case manager. Required resources for this task include a case manager assignment form and contact information for the case manager.
1
Palliative Care Team
2
Nursing Department
3
Social Work Department
4
Case Management Department
5
Other
Coordination with mental health professionals if required
In this task, coordination with mental health professionals is conducted if required. Mental health support is an essential component of palliative care, addressing emotional and psychological needs. The task has a direct impact on the patient's mental well-being and overall quality of life. The desired result is to have a coordinated care approach involving mental health professionals if necessary. The task requires assessing the patient's mental health needs, identifying appropriate resources, and coordinating referrals. Potential challenges could include limited availability of mental health professionals or patient reluctance to seek mental health support. Required resources for this task include a mental health referral form and contact information for mental health professionals.
Discuss DNR (Do Not Resuscitate) orders if appropriate
This task focuses on discussing Do Not Resuscitate (DNR) orders with the patient and their caregiver if appropriate. DNR orders are an important aspect of end-of-life care planning. The task has a direct impact on aligning the patient's healthcare wishes with the care provided. The desired result is to have a clear understanding of the patient's preferences regarding resuscitation. The task requires sensitive communication, ensuring the patient and caregiver understand the implications of a DNR order. Potential challenges could include emotional reactions, cultural considerations, or differing viewpoints among the care team and family. Required resources for this task include a DNR discussion guide and DNR order forms.
1
Explanation of DNR
2
Clarification of Resuscitation Procedures
3
Patient Wishes Regarding Resuscitation
4
Discussion of Potential Scenarios
5
Emotional and Spiritual Considerations
1
Full Code
2
DNR (Do Not Resuscitate)
3
Allow Natural Death
4
Comfort Measures Only
5
Other
Arrange for necessary medical equipment at home
In this task, arrangements for necessary medical equipment are made at the patient's home. Medical equipment ensures the patient's comfort and facilitates the delivery of appropriate care. The task has a direct impact on the patient's quality of life and safety. The desired result is to have the required medical equipment available and properly set up at the patient's home. The task requires assessing the patient's specific equipment needs, coordinating with suppliers, and ensuring proper training for the patient and caregiver. Potential challenges could include equipment availability, insurance coverage, or technical difficulties with setup. Required resources for this task include an equipment assessment form and contact information for medical equipment suppliers.
1
ABC Medical Supplies
2
Medline
3
Hillrom
4
Joerns Healthcare
5
Other
1
Bed
2
Wheelchair
3
Oxygen Tank
4
IV Pole
5
Walker
Approval: Medical Equipment by Nurse
Will be submitted for approval:
Arrange for necessary medical equipment at home
Will be submitted
Provide resources about coping and bereavement support
This task involves providing resources about coping and bereavement support to the patient and their caregiver. Coping with a serious illness and eventual loss can be challenging. The task has a direct impact on addressing the emotional and psychological needs of the patient and caregiver. The desired result is to provide appropriate resources that can help with coping and bereavement. The task requires assessing the patient and caregiver's specific needs, identifying relevant resources, and providing educational materials. Potential challenges could include limited availability of resources or cultural considerations in addressing grief and bereavement. Required resources for this task include a list of support groups, informational brochures, and contact information for mental health professionals.
1
Support Groups
2
Therapy Services
3
Grief Counseling
4
Self-Help Books
5
Online Resources
1
English
2
Spanish
3
Chinese
4
French
5
Other
Review and update care plan as and when necessary
In this task, the care plan is regularly reviewed and updated as necessary. Continuous assessment of the care plan ensures that it remains relevant and responsive to the patient's evolving needs. The task has an ongoing impact on the patient's care experience. The desired result is to have an up-to-date care plan that reflects the patient's current condition and goals of care. The task requires periodic assessment of the care plan, reassessment of the patient's condition, and collaboration with the care team. Potential challenges could include conflicting priorities, changing patient preferences, or limited resources for certain interventions. Required resources for this task include a care plan review form and access to the patient's medical records.
1
Weekly
2
Biweekly
3
Monthly
4
Quarterly
5
As Needed
Routine monitoring of patient’s condition
This task involves routine monitoring of the patient's condition. Regular monitoring helps ensure that the patient's needs are identified and addressed in a timely manner. The task has an ongoing impact on the patient's overall care and well-being. The desired result is to have a systematic approach to monitoring the patient's vital signs, symptoms, and response to interventions. The task requires implementing established monitoring protocols, documenting findings, and communicating with the care team. Potential challenges could include limited resources for continuous monitoring or difficulty capturing accurate data. Required resources for this task include monitoring equipment (such as a blood pressure cuff and thermometer) and a monitoring log.
1
Blood Pressure
2
Heart Rate
3
Respiratory Rate
4
Temperature
5
Oxygen Saturation
Approval: Care Plan Updates by Physician
Will be submitted for approval:
Review and update care plan as and when necessary
Will be submitted
Emergency care planning
This task focuses on emergency care planning for the patient. Emergency situations require preparedness and clear guidelines to ensure prompt and appropriate care. The task has a direct impact on the patient's safety and well-being during emergencies. The desired result is to have an emergency care plan that provides guidance to the patient, caregiver, and emergency responders. The task requires identifying potential emergency scenarios, developing response protocols, and communicating the plan to relevant stakeholders. Potential challenges could include complex medical needs during emergencies or variations in emergency response systems. Required resources for this task include an emergency care plan template, contact information for emergency services, and emergency contact numbers.
