Family Care Services Plan for Providing Care

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Family Care Services Plan for Providing Care

Scope of Service

Family Care Services provides acute, custodial, and respite nursing care on a continuous or hourly basis to patients in their place of residence. Ages of patients cared for by Family Care Services range from infancy to the geriatric population, with 75% of our patients in the pediatric age group. Skilled nursing care is provided by registered nurses (RN) for conditions that require administration of TPN or IV fluids/antibiotics. Conditions treated range from short bowel syndrome to pneumonia. Licensed vocational nurses (LVN) provide a secondary level of skilled nursing care for diagnoses such as ventilator dependent quadriplegia, muscular dystrophy, or developmental delays secondary to congenital anomalies. Certified home health aides (CHHA) provide supportive care to individuals requiring some level of assistance with activities of daily living under the supervision of registered nurses.

Frequent procedures/services/functions

 Pulmonary system support via mechanical ventilation, oxygen, pulse oximetry, bi-level ventilation and apnea monitoring

 Ongoing multi-system patient assessments, care plans, interventions and evaluations

 Nutritional support, TPN and enteral feedings

 Intravenously administered fluids and pharmacological agents

 Infection control and safety management

Hours of Operation

24 hours a day/7 days a week

Office hours are Monday through Thursday 8:00am to 5:00pm, Friday 8:00am to 2:00pm After hours a RN clinical supervisor and staffing coordinator are available

Criteria for Admission into Service

 Patients under the care of a physician and residing within 55 mile radius of LLUMC

 Ability to meet patient needs in the home setting safely with desired outcomes

 Availability of appropriately qualified staff to meet patient needs

 Patient understanding of financial obligations

 Patient able to obtain necessary physical facilities and equipment for care in home setting

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Referral Sources

Received from hospitals clinics, physician offices and other health service providers such as rehab centers and sub-acute facilities. Referrals are also received from Medi-Cal and Inland Regional Center. The agency will conduct an assessment visit by an RN upon physician order to determine appropriateness of care and services needed.

Staffing Plan - Number and Mix of Staff

Nurse Manager 1

Registered Nurses 3

Clinical Supervisors 3

Licensed Vocational Nurses 120

Certified Home Health Care Aides 1

Clerical Support 6

Staffing of Family Care Services, for the provision of extended hours of care, is provided by RNs, LVNs, and CHHAs. They function independently in the patient's place of

residence. Clinical supervisors are responsible for assignment of competent staff, supervision, quality of care delivered, and case management of complex, medically fragile patients. Shift assignments are made by the staffing coordinators with the approval of clinical supervisors and are based on the following criteria:

 Complexity of patient's condition and required care based on the registered nurse assessment

 Type of technology required in providing nursing care

 Competence of nursing staff available

 Geographical location of patient

 Relevant infection control and safety issues

 Relevant psychosocial /family dynamics

Method of adjusting to staffing variances

Staffing coordinators are responsible for making necessary changes in patient assignments as changes in personnel needs occur. These changes must have the approval of a clinical supervisor. Per Diem and part time staff are utilized when there is a high volume of services needed. Patients are not accepted for continuous care unless staff are available to meet the commitment to extended patient care.

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Qualifications of Staff

Qualifications/licenses/certifications required of staff Nurse

Manager  Active California Registered Nurse License\

 Associate Degree in Nursing. Bachelors degree in Nursing/Health Administration/Education or related field preferred

 Basic Life Support (BLS) Certification

 4-5 years acute care nursing experience

 3 years of management experience in a home care setting

Clinical

Supervisors  Current California RN license

 Basic Life Support (BLS) certification

 1 year Home Care Experience

 1 year supervisory or management experience

Staff RN or

LVN  Current California RN/LVN license

 BLS certification

 LLUMC TPN Training (RNs only)

 1 year nursing experience (preferably acute care)

 If less than one year experience, LVN must qualify for program flexibility through Department of Health Services

CHHA _ _{Current California CHHA Certification}

 High School Diploma

 BLS certification

 Complete Skills Competency Assessment

Clerical

Support  High school diploma

 1 year general office experience with basic computer skills

How are in-services/continuing education programs provided to maintain staff competency?

Registered nurses and licensed vocational nursing staff attend monthly case conferences and in-services which are provided based on employee needs, changes in technology, the home care environment, or regulatory requirements. CHHAs, RNs and LVNs also receive a mandatory in-service packet quarterly and must complete post-tests.

Competencies are completed with orientation and as needed for the nursing caseload, and annually.

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Required Competencies

Nurse Manager _ _{BLUE Book}

 Compliance

 Performance Improvement

 Gallup

 HIPPA

 Patient Rights and Responsibilities

Clinical

Supervisors  BLUE Book

 Fire extinguisher training

 Age Specific

 HIPAA

 Fraud and abuse

 Basic cultural competency

 Infection control/standard precautions

 Wound care

 Pain management

 Compliance

 Fall Risk

 Advance Directives

RN Clinical Staff _ _{BLUE Book}

 Age Specific

 HIPAA

 Compliance

 Fraud and abuse

 Performance Improvement

 Pain management

 Fall Risk

 Advance Directives

 Home Oxygen Safety

 Airway management competencies (if applicable to caseload)

 Colostomy/Urostomy care (if applicable to caseload)

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 IV therapies and central line care (if applicable to caseload)

 Bedside glucose testing (if applicable to caseload)

 Wound care (if applicable to caseload)

LVN _ _{BLUE Book}

 Age Specific

 HIPAA

 Compliance

 Fraud and abuse

 Pain management

 Fall Risk

 Home Oxygen Safety

 Airway management competencies (if applicable to caseload)

 Colostomy/Urostomy care (if applicable to caseload)

 Catheterizations (if applicable to caseload)

 Bedside glucose testing (if applicable to caseload)

 Wound Care

CHHA _ _{BLUE Book}

 Age Specific

 HIPAA

 Compliance

 Fraud and abuse

 Pain Management

 Fall Risk

 Home Oxygen Safety Clerical Support _ _{BLUE Book}

 Age Specific

 HIPAA

 Fraud and abuse

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Method of Communication with Other Departments

Internal and External Methods of Communication

Internally and externally, verbal communication occurs daily between members of the health care team and with other departments involved with the care of the patient. Phone, e-mail, and written memos are used to communicate both within and outside of the

Department.

Describe collaborative relationships with other departments

Family Care Services works collaboratively with case managers from LLUMC, other hospitals, payers, and In-Home Operations/Medi-Cal to promote and implement long-term care in the home environment. Verbal and written communications are enhanced via telephone, FAX, pager and computer. The care continuum for Family Care Services utilizes ongoing communication/collaboration with other departments within LLUMC such as: Mountain View Pharmaceuticals, Case Management, and applicable clinic settings. Clinical supervisors participate routinely in the Home Mechanical Ventilator Clinic to promote case management of our patient population.

Goals of Department

 Promote and implement long-term nursing or supportive care in the home to effectively meet the identified needs of our patient population

 Patient satisfaction will remain above 90%, demonstrating service excellence

 Nursing coverage will be above 90% of authorized hours.

Plan to Improve Quality of Service

 Monitor Human Resource Management process to maintain and adequate number of qualified staff while meeting productivity goals.

 Provide ongoing in-services and competency assessments to promote staff performance improvement

 Utilize both patient and staff satisfaction surveys to evaluate and improve quality of care

 Work closely with Human Resource Management for recruitment to maintain and improve nursing coverage, which will improve access and increase patient

satisfaction with services.

 Continue hiring qualified new graduates for program flexibility. Revised: 12/2012