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5 tips to improve and better utilize your home care plans [Free tip sheet]


The caregiver employment crisis has the home care industry on its toes looking for solutions to employee churn. One of those solutions is to evaluate the top complaints caregivers have on the job and improve them to increase employee retention.

In 2021, poorly managed care plans were in the top 10 complaints from care providers and nurses in home care organizations, according to Home Care Pulse. 

Lorraine Toderdash, Senior Product Manager at AlayaCare was invited to Home Care Pulse’s podcast, Vision: The Home Care Leaders Podcast, [see the full episode here] to discuss how to improve your care plans to increase engagement, accountability, and ultimately improve patient care.

Based on this discussion, we’ve developed a free tip sheet to help your home care organizations and healthcare providers work through improving your care plans.

We’ve also compiled some tips to help get you started. Let’s dive into how to make and improve a health care plan and how it can improve your home care agency, nursing home, or business. In this blog, we will cover:  

  • How to make your current care plan into an optimal health care plan  
  • How to create an optimal home health care plan  
  • How to use the Home Health Care Plan Worksheet for your care plan   

How to make your current care plan an optimal care plan  

1. S.M.A.R.T goals  

Before you start your tactic, you should always write out your goals. S.M.A.R.T. goals represent specific, measurable, achievable, relevant, and time-oriented goals.   

How this helps the caregiver or nurse:  

Making your goals and objectives SMART for the caregiver allows for an objective measure when care or service is completed.   

How this helps the client:

Making your goals and objectives SMART for the client allows for informed consent and agreement on the goals of care.  

“It’s really important to the goals that we put in place, because those are what we’re going to use to measure and to identify when we’re done. So, you know, it gives us a definition of done as well as allows the clients who were doing our care planning with, because it’s an interactive process to understand what we’re looking at for the goals of care.” – Lorraine Toderdash  

  2. Assign care plan actions   

Action plans are especially important for interventions to a discipline/individual. Items not assigned are often missed and can result in gaps in care.  

How this helps the caregiver or nurse:  

Assigning care plan actions will help the caregiver keep themselves and the agency accountable, as well as avoid issues from falling through the cracks and not getting addressed.   

How this helps the client:

Assigning care plan actions will help the client by providing a clear understanding of the full circle of care, as well as ensuring the client’s care needs are met.   

 “I’ve done both quality reviews in my career. I’ve also been the nurse who’s been, you know, reviewing the care plan, getting ready for discharge. And all of a sudden, I find this entire area that has not been addressed. And it, it happens no matter, you know, no matter what, but in some cases, it can delay a discharge. If you, if you don’t have those mechanisms in place or you don’t have those plans in place. In other cases, you know, it’s, it’s really that understanding. So, it, it results in something becoming much less smooth for the client. You know, they, they have an expectation of the care that’s being provided and when that entire gap happens there, it can be, it can be really challenging to recover from, and, and it can result in, you know, having to provide additional service just to make that.” – Lorraine Toderdash  

3. A balance between clinical best practices and client-specific needs 

Use care plan libraries wisely by balancing the clinical best practices and what your clients need. 

How this helps the caregiver or nurse:  

Balancing care plans between clinical best practices and your client-specific needs will help the caregiver expedite the client care plan-building process. Avoid staff missing a standard of care item.  

How this helps the client:

Balancing care plans between clinical best practices and your client-specific needs will help the client engage in their own health planning and allow them to understand standards or usual practices.  

“Well, it helps the caregivers deliver better care because you, you know, you kind of go into that situation, understanding what’s needed what’s in place and having your care plan, align with those practices, as well as identifying where there needs to be a nuance in there because of the individual client’s requirements is, is incredibly helpful. And having that documented for them to support them is really important.” – Lorraine Toderdash  

 4. A care workflow  

Incorporate the care plan into the care workflow to drive activities on care plan content, avoid double entry (solution or system support), and document directly to the care plan.  

How this helps the caregiver or nurse:

Incorporating the care plan into the care workflow will allow caregivers and nurses to work towards specific goals, ensure documentation supports the care plan and allow them to make incremental evaluations.   

How this helps the client:

The client will gain visibility into their progress, see their incremental changes and help them avoid discouragement when they can see smaller goals being achieved.  

“It’s really important to make sure that your care plan is involved in the workflow. So, making sure that you’re not duplicating your documentation, you’re not resulting in discrepancies because you’ve got your care plan on one hand, and you’ve got the actions that you’re completing on the other hand.” – Lorraine Toderdash  

 5. Evaluations   

Evaluate not only the goals that are being met but also those goals that are not met. Make sure to evaluate prior to the discharge date so that plans can be made – e.g. referrals, extending services, etc. Identify where progress to goal completion is not being made and adjust. 

How this helps the caregiver or nurse:

Evaluating goals will help the caregiver or nurse meet regulatory requirements, verifies that the care plan was completed (or not), and allows for adjustments to be made to interventions that are not working.  

How this helps the client:

Evaluating goals will help the client be involved in their own health journey and own their health and wellness, celebrate goals achieved, and provide feedback when goals are not met.  

“So, what am I doing currently? What’s working well, what is challenging to the, to the other providers, the organization, or what’s been challenging, or what’s been the feedback from the clients because the clients have, have perspectives on the care that they’re receiving and whether or not it’s meeting their needs as well. And then using that as your steppingstone to go forward.” – Lorraine Toderdash  

How to make an optimal home health care plan for patient-centered care  

It’s no easy feat to create the optimal care plan, but by keeping in mind the 5 tips listed above provided by Lorraine, you are one step closer to creating the best home health care plan for your team.

An optimal health care plan should be a patient-centered care plan with SMART goals, care plan actions assigned to individuals, a balance between clinical best practices and client needs, a care workflow, and evaluating goals.

To help you create an optimal health care plan with these 5 tips in mind, you can use the free downloadable worksheet created by Lorraine Toderdash and AlayaCare to make sure you can successfully implement these strategies into your care plan to start improving patient outcomes.

How to best use the home health care plan tips worksheet for your business 

The Care Planning Tips worksheet covers the 5 tips Lorraine introduced above and how to implement them and maintain the process. Sometimes writing things down can make all the difference! Seeing your current health care plan written down in front of you, what changes you need to make, how to make those changes, and how to keep them going allows you to see the full picture.   

The worksheet explains “Tip #1: Make SMART goals” and how it can help caregivers and clients. The worksheet is then broken down into two columns, how to implement it and how to maintain the process.   

In the implementation section, the worksheet walks you through what needs to be done in your current process and asks specific questions on whether your current process meets your chosen SMART goals.   

As you answer each question related to your SMART goals, you’ll have a clear path of how you can implement them into your existing workflow/care plan.   

In the maintain the process section, the worksheet walks you through the best practices on how to maintain your SMART goals in your care plan without falling astray.   

Download the free tip sheet today and get started on improving your care plans to create improved caregiver satisfaction and better patient outcomes.

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