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LTC Clinical Care Delivery Processes Cheat Sheet by

LTC Clinical Care Delivery Processes
processes     care     healthcare     ltc     delivery     clinical

Step A1: Assessment

1. Obtain and review inform­ation including:
     Personal and medical history including physical, functi­onal, psycho­social inform­ation
     Past medical history and physical, diagnostic tests, laboratory results, practi­tioner orders, medica­tions
2. Observe patien­t/r­esi­dent.
3. Conduct physical assessment including review of systems, functi­onal, cognitive and other specialty assess­ments.

Step A2: Problem Identi­fic­ati­on/­Dia­gnosis

Problem Identi­fic­ati­on/­Dia­gnosis – What is the problem?
1. Use clinical judgment to interpret and analyze data.
2. Identify how existing symptoms, signs, diagnoses, test results, dysfun­ctions, impair­ments, disabi­lities, and other findings relate to one another.
3. Identify the need for additional analysis and interv­ention
4. Define signif­icant risk factors.

Taken Together

Taken together, these first two steps enable the clinician to develop pertinent, indivi­dua­lized care plans and interv­ent­ions.

Step B: Care planning

How to manage the identified problems
1. Define overall goals and objectives for services and care with the indivi­dual.
2. Set priori­ties.
3. Identify risks and benefits of treatment options.
4. Select approp­riate interv­ent­ions.
5. Clarify prognosis.
6. Write plan of care.
 

Step C: Interv­ention and Monitoring

Putting the plan into action
1. Utilize the care plan to coordinate and provide care for the indivi­dual.
2. Identify and implement interv­entions and treatments to address the indivi­dual's physical, functional and psycho­social needs, concerns, problems and risks.
3. Administer treatments and services.
4. Monitor condition and response to treatment and interv­ent­ions.
5. Manage complex situations and compli­cat­ions.

Step D: Evaluation

Did the plan work?
1. Evaluate the effect­iveness of the interv­entions and the approp­ria­teness of the care plan.
2. Identify course of condition, success of interv­entions and progress toward goals.
3. Identify factors that are affecting progress towards achieving goals.
4. Adjust treatments and interv­entions based upon indivi­dual’s response.
5. Continue to implement and evaluate care plan.
6. Reassess and identify when care objectives have been achieved suffic­iently to allow for discharge, transfer, or change in level of care

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