Home Health Excellence: Developing the Plan of Care

Presented by Kim Tate and Natalie Venable

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Video Runtime: 21 Minutes; Learning Assessment Time: 48 Minutes

This course addresses the need for home health clinicians to enhance their skills in creating individualized and patient-centered care plans. Participants will learn the key elements of the plan-of-care development, including identifying patient-specific interventions, setting measurable outcomes, and fostering interdisciplinary collaboration. By focusing on practical applications and regulatory compliance, this course prepares clinicians to deliver high-quality care tailored to each patient’s unique needs. The course is designed for home health clinicians who perform home health admissions, plan of care update orders, resumption of care orders, and recertifications.

Learning Objectives

Define the key elements of plan-of-care development
Outline how the plan of care serves as a road map for care delivery
Identify patient-specific interventions based on comprehensive assessment data and specific physician/practitioner orders
List measurable outcomes and goals for the plan of care
Recognize the impact of an accurate plan of care on skilled care delivery

Meet your instructors

Kim Tate

Kim Tate is a registered nurse with over three decades of healthcare experience. She is a passionate clinical leader who strives to deliver quality care and positive patient outcomes. She has a bachelor of science in nursing with a proven track record of facilitating and leading the effectiveness of clinical programs,…

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Natalie Venable

Natalie Venable earned her bachelor of science in occupational science from Eastern Kentucky University in 2012, followed by a master of science in occupational therapy in 2014. Her extensive career as an occupational therapist spans various settings, including outpatient care for both adult and pediatric populations, skilled…

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Chapters & learning objectives

1. Introduction to Plan-of-Care Development

This chapter will cover the fundamental aspects of the plan-of-care development, emphasizing its definition, importance, and key elements. Understanding these basics is crucial for clinicians as it lays the foundation for creating effective, individualized care plans that ensure high-quality, patient-centered care and compliance with regulatory standards.

2. The Plan of Care as a Road Map

This chapter will explore how the plan of care serves as a road map for delivering individualized, patient-centered care. By understanding the key concepts of care planning and incorporating the 4Ms framework, clinicians will be able to create effective plans that guide the frequency and duration of interventions, ensuring comprehensive and coordinated care.

3. Patient-Specific Interventions

This chapter will delve into the process of identifying and implementing patient-specific interventions based on comprehensive assessment data and physician/practitioner orders. Understanding how to link assessment findings to tailored interventions is vital for addressing individual patient needs effectively and improving overall care outcomes.

4. Measurable Outcomes and Goals

This chapter will focus on the importance of establishing measurable and achievable goals within the plan of care. Clinicians will learn techniques for setting realistic outcomes, which are essential for monitoring progress, adjusting interventions as needed, and ensuring that patient care remains goal oriented and effective.

5. Patient-Centered Care and Desired Outcomes

This chapter will emphasize the significance of interdisciplinary collaboration in achieving patient-centered outcomes and the role of an accurate plan of care in improving patient outcomes. Clinicians will learn how to evaluate progress toward goals and update the plan of care accordingly, ensuring continuous improvement and optimal patient outcomes.