For skilled nursing or therapy services, there will be a certain number of visits per week for a certain number of weeks, to address the specific diagnoses which necessitate the home health care episode and specific physician orders for skilled services. If a home health aide is needed to assist with personal care during recovery at home, that service will also be included. Respite care to relieve family caregivers may by appropriate.

In the case of chronic illness/disability, specialized plans of care are developed to address coping skills that will promote adaptation and adjustment to life changes, in order to effectively manage a chronic condition and attain/maintain the highest level of independent function and quality of life.

For a child, the plan of care is age appropriate, assessing developmental milestones achieved, family dynamics and interaction patterns, and providing teaching and anticipatory guidance for the parent or caregiver regarding the illness/injury, treatment plan, and specific skills that family members need to learn in order to properly care for the child. Our pediatric division is developing several programs that will provide comprehensive home care services to children and thier families.

Once the plan of care is completed, the nurse submits it to the client’s physician for review and signature. The nurse acts as case manager, coordinating all of the health care providers, equipment suppliers, and community resources involved in the client’s home care, in order that goals of care may be achieved effectively and efficiently.