CLIENTClient self-referrals are triaged using our initial screening tool. Referrals from organizations include clinical info and may have different priority pathways. Both are logged, acknowledged within 2 business days, and followed up with intake assessment.
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.
GOALSService plans are developed collaboratively with clients and families, documenting goals, interventions, and progress. Plans are reviewed regularly and updated based on changing needs. Clients and families are involved in planning and decision-making throughout their care.
PARTICIPATIONWe collaborate through: joint planning and program development, shared service delivery, information sharing and referrals, participation in community health initiatives, coordinated response to public health issues (outbreaks, immunizations), shared training/education, regular communicati
AUTONOMYWhen professional goals differ from client preferences, I explore the reasons for the difference through respectful dialogue. For example, if I recommend therapy frequency but the client wants less, I discuss the clinical rationale while listening to their concerns (cost, energy, other pri
PARTNERSHIPKey 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
RESPECTTreating clients with courtesy, listening to concerns, protecting privacy, honoring preferences. Includes cultural, spiritual considerations. Staff trained in person-centered approach. Essential to quality care and resident rights.
EMPOWERMENTEmpowerment in community health services involves systematic assessment, planning, implementation, evaluation. Staff trained on standards, procedures documented, outcomes monitored. Quality improvement when gaps identified. Aligns with accreditation requirements.
INDIVIDUALService delivery is client-centered: comprehensive needs assessment, individualized service plans, flexible scheduling, regular progress monitoring, and coordination with healthcare providers and community resources.
