Patient or person centered care is better in home care because the needs, values and preferences of the patient are at the heart of the plan of care.  This creates a sense of self-determination, acknowledging that the client has a major role to play in recovering or maintaining quality of life.

Patient centered care creates a framework, a list of goals and plans of action to reach them, goals established by talking with the patient. 

In nurse case management, a holistic, comprehensive evaluation is performed where the nurse will evaluate the patient/client’s strengths, needs and preferences, not just the problems that have arisen.

There are nine categories evaluated including 1. health/mental health, 2. cognition/behavior, 3. functional status, 4. environment/home safety, 5. psychosocial support system, 6. finances and resources, 7. legal documents, 8. cultural identity and 9. spiritual beliefs.

The patient or client’s health/mental health is a medical history along with input from the client, family members and the client’s physician.  Current medications are reviewed along with checking potential interactions and providing education as needed. 

Cognition/behavior are evaluated to see if there is any memory loss or change in judgement. 

Functional status is a measurement related to ADL’s, or activities of daily living.  The nurse will evaluate how the patient/client is able to ambulate (with or without assistive devices such as walker or wheelchair), how well he or she can transfer from a bed to a chair and back, get dressed, get to the toilet, and how well the client/patient can bathe himself/herself and handle basic hygiene such as brushing teeth.  

An environmental or home safety check identifies any hazards that need correcting.  If there has never been an emergency plan, the nurse will create one with input from the patient/client.  The nurse will note any history of falls, whether nutrition is adequate, if there are issues with driving, use of substances such as drugs or alcohol, any potential abuse & neglect or judgement issues.  

When considering the patient/client’s psychosocial support system, the nurse will evaluate what type of informal support the client has, whether from friends, neighbors and children.  Formal support such as paid caregivers will be assessed, along with the adequacy of the current arrangement and whether more support is needed. The nurse may address feelings of loneliness, depression, loss/grief or stressors in the client’s life. 

A financial/resources evaluation evaluates whether the client is able to access current medications and doctor’s appointments, whether there is long term care insurance in place to assist with funding care and whether the client has a system of paying bills and avoiding financial scams. 

Legal documents to be discussed include Advance directives and end of life care, powers of attorney for health & finance, Wills & Trusts, conservatorship/guardianship if applicable, and public benefits eligibility if a referral should be made. 

A client’s cultural identity is noted along with the activities that give the client joy and meaning.  The client’s dislikes are also noted. 

Finally a client’s spiritual beliefs are integrated into client centered plan, regardless if the client defines himself or herself as agnostic or identifies with a formal religion. 

Based on the client’s needs, strengths and preferences, the client and nurse will formulate smart goals, ones that are realistic and measurable in a defined period of time.  Having a clear goal shows the client and the care team what they are working to achieve, and how long it’s expected for a particular outcome to be successful. 

The patient/client is encouraged to participate as much as possible in this patient centered care to create a framework for teamwork between the client, family, trusted partners and the nurse and caregivers or home care agency. 

If you are in need of quality care management, call At Home Nursing Care at 888-634-8004 for more information.