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| When a home care referral
or request is received at Tri-County Home Nursing Services,
Inc. our Patient Care Director will assess the inquiry
and determine services based on the following criteria: |
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The patient needs full-time or part-time
home care services. |
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The patient lives in the geographical
coverage area of TCHNS, Inc. |
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The referral source and physician is
willing to authorize the services. |
The Six Crucial Points of our Admission Process
and Continuum of Care are as follows:
| 1 |
INITIAL CONTACT
The Patient Care Director will contact the patient
or responsible person with any additional questions
and to verify information. Then, based on the "patient
profile", a determination is made whether or
not the patient meets the admission
criteria. The patient, referring agency, or
responsible person is informed of the decision to
accept or decline the patient for admission. |
| 2 |
NURSING ASSESSMENT
Once accepted for admission, the initial professional
contact with the patient is within 24/48 hours after
the admission has been approved or as soon as possible,
depending on the circumstances. |
| 3 |
PLAN OF CARE
Our Patient Care Director will develop a Patient
Care Plan specific to the patient. This plan will
be developed based upon the initial nursing assessment
of the patients’ physical impairments, medical
& surgical history, mental status, medications
and current therapies. An evaluation of the patients
living environment including family situation and
medical equipment will be made. The Patient Care
Plan will be monitored on a regular basis. We keep
records of services performed and the patients’
condition and progress. A clinical chart and scheduling
record is started for the patient according to the
physician’s treatment plan, care plans from
the referring agency and the Patient Care Plan developed
by Tri-County Home Nursing Services, Inc. |
| 4 |
PERSONAL CARE AIDE MATCH
An appropriate Personal Care Aide is matched
up with the patient and assigned to start home care
services. The Personal Care Aides report changes
in the patients’ condition to our Patient
Care Director. |
| 5 |
PATIENT MONITORING
Patient monitoring of home care services is done
throughout the continuum of care from admission
to discharge. A Tri-County Home Nursing Services,
Inc. Registered Nurse will routinely administer
nursing assessments on patients’ monthly or
quarterly depending upon the Physicians’/Referring
agencies indicated by service needs. Our Patient
Services Coordinator and Patient Care Director maintain
telephone contact with the patient/family. |
| 6 |
24 HOUR COVERAGE
Tri-County Home Nursing Services, Inc. provides
Registered Nurse coverage 24-hours, around-the-clock,
seven-days-a-week. Our nurse is always available
for information and problem-solving for patients
and staff. Also, she/he can provide nursing intervention,
telephone assessment, or professional advice during
an emergency situation. |
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