Friday, November 13, 2009

Care Management in Assisted Living

PALs software supports the following 5-step process of Care Management (or Case Management) in Assisted Living Settings.

1. Resident Assessment - To identify resident needs. In most states an RN does this assessment, other states permit a "manager's assessment".

2. Service Negotiation - identifying which assessed needs will be met and how. Also, resident "wants" may be added.

3. Service Plan or Agreement - a signed agreement between the Assisted Living Provider and the Resident (or their representative) identifying the services to be provided to meet both resident needs and wants. These services will customized for the resident, and will provided at a stated time and frequency (daily or weekly or...). Finally, the cost of these services will be itemized (or combined into a monthly package).

4. The Service Plan is supervised on some schedule, based on agency policies, or state licensing requirements. In many states where services may involve delegated nursing, the services are supervised more frequently the services that are not delegated. The most common nursing delegated service is medication administration. The purpose of the regular plan supervision is to determine if the current plan is meeting the resident's needs and preferences. If there is a change in condition, a new assessment and service plan may be negotiated.

5. Re-Assessment. The may start the process anew. Most states require an annual physician review that most providers precede by a nursing assessment which accompanies the resident. In this way, the physician and Care Manager are coordinating services.

PALs supports the above process in the following ways.

1. Assessment templates are provided for Care Managers that can be edited to fit their preferences, program specialties, and state requirements.

2 & 3. Service Planning is supported by selecting services from approved services based on licensure then customizing the service for the individual resident based on the resident assessment and “wants”. These services are assigned to a shift and scheduled for a specific time and day(s). This same information is used to create a Resident Agreement to be signed, shift assignment sheets, service documentation forms, and invoices.

4. Based on the services provided, if they are Nurse Delegated or not, and state licensing requirements, PALs will compute the date for the next plan supervision. PALs also provides a plan supervision form, for the nurse to document their finding regarding the appropriateness of the plan to the residents current health care needs and preferences, staff competence in providing the service, and resident’s evaluation of the service provision. Also the service documentation forms may be reviewed noting any variations (added or cancelled services). Based on the date of this interview, the next plan supervision is computed. So the nurse may print an up-to-date plan supervision schedule at any time.

5. Finally, at the time of physician review, at least annually by regulations, the nurse is again prompted by PALs to complete a re-assessment prior to the physician visit and PALs will print a form summarizing the nurse's recommendations and current treatments and medications for physician review and signature. A list of upcoming required physician visits can be printed at any time.

The above process has proven effective in meeting state requirements as reflected in state surveys.

For more information, visit our website at www.PALsSoftware.com and consider downloading a trial version.

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