Below is a summary of steps taken when receiving home care from the time you decide Self‑Direct is right for you.
- A Registered Nurse (RN) will follow up with the referring person or participant to schedule an initial assessment. The RN will assess the participant’s level of care and assist in developing a schedule with the participant and/or family. They will also discuss all preferences and needs to best match a caregiver to the participant.
- The RN creates a plan of care for each patient based on a professional assessment of the patients needs and includes pertinent diagnosis, prognosis, mental status, frequency of each service to be provided, medications, treatments, diet regimes, functional limitations and rehabilitation potential which includes but is not limited to the description and frequency of each health care service provided, required treatment and procedures.
First day of service
- Family, Scheduling Team, and Nursing Team verify the opening date of service
- The RN orients the staff to the plan of care and supervises the staff in the completion of care tasks
- The RN ensures that all medications are in adequate supply as well as reviews safety items or challenges in the home
- The RN reviews the backup and emergency plans
Ongoing Care
The plan of care is revised as frequently as necessary to reflect the changing care needs of the patient but no less frequent than every sixty days.
- Care schedule can be adjusted as needed by the family/loved one
- The RN supervises the aide every 90 days in the participant’s home or more frequently if there has been a change in the participant’s medical condition.
- The RN visits the participants home and reassesses their needs and quality of service provided every 6 months or if there has been a change in the participant’s medical condition
- The RN works with physician and insurance companies to ensure re-authorization of services or any necessary increases/decreased in hours due to changes in health status or family support availability
