Nursing Home Social Services Reference/Flow of Care/Initial Care Plans

Initial Care Plans After assessments are done, and a case coneptualization or formulation has been developed, an initial care plan should be developed, and reviewed with resident and family and other departments at a care conference. This plan will be recorded in the chart for the resident with the care plans for nursing, activities, dietary and other departments. The social services plan should focus on behaviors, cognitive supports, counseling services, and case management issues for this resident. Some will be similar to other residents, but there should also be components that are tailored to the specific resident. Care plans generally address areas of concern for all residents such as adjustment, behaviors, mental health, developmental goals, family / community relations, socializing, and spiritual health. Within these general areas, there are specific issues and interventions that are documented as needed with the format: issue, intervention(s), expected response(s). This is related to the standard process chart of input, process and outputs. These IPO charts are intended to help document and respond to the specific client system or systems. The social services care plan should support the care plans of other departments and can and should refer to other care plans. For example, medication used as an intervention for a client mental health issue such as depression would refer to nursing care plan regarding dosing and administration of the medications. Social services will be documenting efficacy of the medications and dosage with assessments and observations of mood states at a certain period with the goal of reducing behaviors indicating depression and increasing socializing, participation in the community and activities. Indications of the use of client strengths in the interventions is encouraged. This might look like this: + Psychological Care Plan for Client X Issue Intervention ResultsDepression Medication - as Rx'd per nursing plan Mood improvement AEB increased time out of bed, more exercise, use of res strengths (humor, social skills), eating in cafe, making friends Note that resident's strength of social skills is mentioned and measured with size of the community of friends. Any increase is acceptable, so a specific number is not required in this case. Of course, at some point the community of friends will become sufficient and should be removed from the plan at that time. Depression should remain in the plan with continued assessment as the intervention and a goal of showing subacute levels per GDS or other assessment tool. Depression might be removed if in the opinion of the doctor or psychotherapist it has resolved such as the depression that is associated with grief or adjustment. Other issues identified at intake require equivalent planning. Some of these may be short term issues such as adjustment or mobility related to conditions that precipitated the transition to the nursing home that might be resolved with healing. Document all of the issues that were identified by the admissions department, nursing and PT/OT and SLP intake that cause issues that relate to social services roles. Case management goals such as applying for or maintaining benefits, arranging counseling or religious services or discharge plans should be documented in this initial treatment plan. Then the task is to follow the plan and document in the chart when interventions were applied and the results achieved, if any. This will assure that the facility and social services pass the State survey.