| 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: |
 |
The patient needs full-time or part-time
home care services. |
|
The patient lives in the geographical
coverage area of TCHNS, Inc. |
|
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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