and Care Planning Strategies
Mary Curry Narayan, PhD, RN, HHCNS-BC, CTN-A
- A warm, caring trusting relationship with the pt is crucial to effective patient-centered/culture-sensitive assessment; care planning.
- While coming to the patient’s door, mindfully prepare to care about the unique, valuable person within each patient.
- Develop a genuinely warm, caring relationship with the patient; family. Project friendliness, kindness, non-judgement in facial/body language. Be present, pleasant, and positive.
- First visit: Introduce self and your role. Use patient’s formal name, then ask, “Is that how you would like to be called?” Greet family present and recognize they may have information or questions.
- Be polite according to the pt’s etiquette norms (e.g., accepting food or drink, leaving shoes at door). See Country and Culture Guides. (www.commisceo-global.com/resources/country-guides).
- Take time to socialize before getting down to business. Share a little about yourself to show you are like the patient in some ways. (e.g., “What a cute dog! I have a dog too!”)
- Sit down at eye level with pt. Make eye contact and appear “relaxed’ (not time pressed.)
- Meet patients “where they are at” physically and emotionally. “You seem to be in pain or tired, discouraged, worried, etc.” Listen empathetically. Fix any problems immediately if possible.
- Tell patient that your relationship will be a collaborative one. “We will work together to help meet your goals. I want to learn how I can best help you if what I am doing isn’t working for you.”
- Encourage pt to share their story. “What happened? What do you hope will happen?”
- Ask about the patient’s concerns, priorities, values, preferences, lifestyle; hopes for the future.
- Maintain “unconditional positive regard” for the patient. Care about what the pt cares about.
- Match what you say and do with patient’s health literacy and culture/lifestyle norms.
- Reflect on any feelings or assumptions you have about any group the patient may be part of. Manage the risk for bias with patient-centered/culture-sensitive care.
- Build trust with continuity of care, showing you are on the patient’s side, caring about what they care about, showing that you care about what is happening to them.
- Be patient-centered, not task-oriented. Go beyond the OASIS to assess patient’s concerns & situation.
- Be culture-sensitive, not culture-blind. Ask how you can make the patient’s care (culturally) comfortable for the patient.
- Be holistic. Assess factors that may compromise the patient’s ability to achieve good outcomes, even though not included on OASIS, such as social determinants of health (e.g., education, finances for nutritious food; transportation for appointments).
- Assess the patient’s concerns, priorities, health values, preferences, goals for health care.
- Assess patient’s motivation and confidence in the physician’s orders for diet, exercise, med adherence, etc. Ask, “On a scale from 0-10, how important is it for you to make this change? On a scale from
0-10, how confident do you feel about making this change?” (If pt not confident, break discharge goals into short term, easy-to-attain goals to gradually achieve goals.
- Assess the psychosocial factors that affect the Care Plan (e.g., family relationships/roles, mental health, finances, spirituality, coping mechanisms, etc.)
- Assess learning needs that affect the teaching plan (e.g., health literacy, gaps in knowledge, motivation to learn, confidence in achieving goals).
- Follow up on patient concerns and any clues the patient drops about additional issues.
- Use open-ended questions; conversational approach as much as possible. Avoid interrogation. Know the OASIS well enough to ask some questions in a conversational way.
- Listen attentively, deeply, and actively to patient’s responses. Pick up on clues that something else needs to be addressed. Summarize what you heard to allow clarification.
- Before physical assessment, ask permission to touch patient or remove clothing.
- Helpful Questions to promote a patient-centered assessment:
- Tell me a little about yourself: your family, activities you like, your hopes for recovery/self-management.
- How do you think I can I best help you?
- How do your health issues affect (or how are they affected by) your cultural/spiritual/ lifestyle beliefs, values and goals?
- I would like to learn more about your culture. Could you teach me about it, especially how it might affect your health and our healthcare services?
- How does your health problem affect activities that are important/meaningful to you?
CARE PLANNING SKILLS
- Engage pt in the care planning process by first identifying patient’s health-related goals. “What are your healthcare goals? What do you most want to do after you recover?” Frame your clinical goals for the pt into the patient’s goals (e.g., “To reach your goal of playing on the floor with your grandchild, I will give you a progressive home exercise program.”)
- Collaboratively determine specific strategies to take patient from current status to patient’s desired goals. What does the patient think will be helpful? What does the patient think will not work? Why? Using creativity, adapt strategies to patients’ values, preferences, culture, lifestyle.
- To promote learning, include teach-backs, return demonstrations and asking pts to record the activities they do each day to reach goals (e.g., recording daily weights, keeping a med record, whatever the pt is trying to learn/make part of their lives) in your plan to coach the pt to success.
- Evaluate progress regularly. “Tell me how things went this week in achieving your goals.”
- If pt is making expected progress, celebrate the success with the pt.
- If pt is non-compliant or not making progress, search with pt for the causes of problems or barriers to progress. Brainstorm, problem-solve solutions to barriers (e.g., if patient not adhering due to side effects to a particular med, discuss with PCP if there are alternate meds).
- Special interventions to include in your patient care plan, if patient needs them:
- Plan for continuity of care (one trusted clinician) to promote attainment of goals.
- If pt at risk for hospitalization/emergency care, assess pt for S/S of “red flags” frequently. Determine self-management plan to avoid hospitalization/emergency care post discharge.
- Regularly review medications for effectiveness, adherence, knowledge, side/adverse effects, new/changed medications, ability to obtain prescriptions. (Med issues are frequent reason for hospitalization/emergency care.
- Use “Stepped Action Plans” (i.e., chunking discharge goal into several short term goals.
- Beyond teaching, use coaching techniques. Use SMART goals & techniques to increase patient’s self-efficacy.
Copyright: Mary Curry Narayan 2023
Available at https://marynarayan.com/Clinical-Resource/
May be copied for clinical or education purposes without permission.
Based on a research study supported by a grant from the Research Institute for Home Care.