| Identify patient's goals |
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“What do you think we need to work on? This is what I think? What do you think? What are your goals? What's your most important goal?” P4 What does the patient expect and hope for related to their health problems? What do they want? What are their goals? What are the barriers that they may face? P16 “I ask them ‘What do you want to get out of our services? What are your health goals? What do you want to see happen in X amount of time?’ A lot of patients have a real hard time coming up with their goals. Often I get to help them through thinking about what their goals might be. Then we have a discussion about what their goals are and what my goals are. You address the goals each time you go to see the patients. What I typically say when I go back to the patient, ‘In terms of reaching your goals, what went well this week? What could have gone better, or what didn't go so well?” P17
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| Engage patient & caregiver in planning |
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Tell the patient that home care is a team approach and that they're part of that care team and that the goals we're working on should be ones the patient is invested in. Any goals you come up with, you have to assure the patient agrees because if the patient doesn't see the value in the goal, you won't get the outcome you want. P11 After establishing the goals, say, “Let's make a plan together to reach these goals.” P14
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| Tailor the care plan to patient |
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Really individualized care is the hallmark of what we need to do. P8 Think of the person as an individual, their background, their culture, who they are, listen to them and develop a plan of care based on all that information. P10 The computerized diagnosis-based care plans are helpful, but they need to be individualized to each patient. P15 What's going to improve their life given their healthcare situation? Develop that plan of care and incorporate their desires. P16
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