CENTEREDMy role includes conducting comprehensive assessments, developing person-centered service plans, providing skilled care, coordinating with the healthcare team, monitoring progress, and documenting care provided.
PREFERENCESWe wanted to develop a diabetes management program. We held focus groups with clients to understand needs/preferences. They told us timing and transportation were barriers.
BIOGRAPHYBiography in long-term care involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
MEANINGFULClient and family input shapes our investigation process by including their perspective on what occurred, the impact on the client, and their concerns or questions. We interview clients and families early in the investigation, incorporate their observations into our analysis, and share fin
ENGAGEMENTKey indicators include: number of community members served, health status improvements, wait times, readmission/ED visit rates, falls prevention, client satisfaction, community awareness, partnership engagement. Also track population-specific indicators like chronic disease management, imm
INDIVIDUALITYIndividuality in long-term care involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
RELATIONSHIPSWe support our network by: maintaining relationships with community partners, sharing info about services at different locations, coordinating warm handoffs between programs, attending community networking meetings, providing education about our services to partners, tracking referrals bot
ENVIRONMENTWe use the PIECES model (Physical, Intellectual, Emotional, Capabilities, Environmental, Social) and standardized assessments (e. , RAI-MDS) to capture a holistic view of the client's health. Documentation is maintained in the client health record/chart.
ACTIVITIESWe obtain consent for info sharing, communicate via secure methods, participate in care coordination meetings, and ensure smooth transitions by documenting all coordination activities. At SJHCG, care coordination uses Caseworks, Oscar Pro, and Care Dove platforms to share information with
EMPOWERMENTEmpowerment in long-term care involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
