Dr Melissa O'Connor Discusses Tips on Creating Personalized Care Plans for Older Adults in Home Health


Melissa O'Connor, PhD, MBA, RN, FGSA, FAAN, endowed professor in Community and Home Health Nursing, M. Louise Fitzpatrick School of Nursing, Villanova University, and director, Gerontology Interest Group, noted that a comprehensive assessment of each patient is necessary to develop individualized care plans that can achieve better outcomes and keep older adults in the home setting.

Garnering as much information as possible from the patient, their electronic health record (EHR), and caregivers is vital to create personalized care plans for older adults in home health and achieve better outcomes, said Melissa O'Connor, PhD, MBA, RN, FGSA, FAAN, endowed professor in Community and Home Health Nursing, M. Louise Fitzpatrick School of Nursing, Villanova University, and director, Gerontology Interest Group.


Can you discuss some considerations for skilled home health nurses in managing older patients?

Some considerations that I would add is having as much information about the patient as possible. Sometimes in home health, we have very little information, you often have a name, an address, a diagnosis, a phone number, and that's about it. You don't always have access to the complete picture of past medical history. If clinicians are able to obtain that information, whether it be through a discharge summary, checking the EHR, that is really setting you up for a huge advantage. But keep in mind, not every patient will come to you with that kind of information.

Conducting a complete and solid assessment as much as possible, garnering as much information as possible from the patient if they're able to share with you. If you're able to speak with caregivers, of course with patient permission, that is also going to put you at a huge advantage when you go to develop their individualized care plan.

Developing a care plan that's unique for them that will hopefully meet as many needs as possible is absolutely ideal. There is a lot of paperwork that goes on in home health. We have the Outcome and Assessment Information Set, which we fondly refer to as the OASIS. And that is a huge, over 100-question tool that is really used for reimbursement. But that's not the end all be all; we still need to conduct a really thorough assessment that's critical, and then develop a plan of care based on that.

Also working in collaboration with the interprofessional team, and that includes home health aides, social workers, physical occupational and speech therapists, often nutritionists, could be a psych nurse practitioner, and also physicians and their team could be a community-based nurse practitioner. Working as a team, we know that older adults will have better outcomes. If everybody's clear on what the patient's goal is for their care, that is also critical. And trying to maximize every visit possible.

Trying to make sure that very important time period of the first 2 weeks of home health when patients are transitioning typically from an acute care or rehab or skilled nursing facility into home health. Sometimes they're transitioning from the community into home health, we know that that's a really important time to really pay attention to what's going on so that we can keep them out of the hospital. Patients don't want to be in the hospital, and we know that they're at risk, when they do go into the hospital, for medical errors. They're at risk for reduced functional status.

So, we need to do everything we can to keep them at home. Not everyone can stay at home, of course, sometimes people do need to be readmitted to the hospital and that's OK. But if we can do an excellent assessment, a deep thorough assessment, formulate an excellent plan of care in collaboration with the team, including physicians, social workers, everyone I mentioned, hopefully we can provide better care, achieve better outcomes, and keep older adults out of the hospital and at home, which is where they want to be.

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