Plan of Care (POC) | Policy and Procedures
When patients are actively involved in the development of their plan of care, the team can work with them to truly individualize the plan to meet the patient’s goals and improve treatment outcomes. Increasing patient participation in their individualized Plan of Care is a CMS patient engagement focus.
The Network has developed and identified several resources to assist facilities to improve their process and increase active participation.
All About You Review
“All About YOU Review” Plan of Care Toolkit was created to help increase patient participation in their plan of care. These resources are a starting point to incorporate into facility practices to re-brand the plan of care and improve patient engagement. In addition to the resources that we have developed, this toolkit also includes an appendix with other supporting documentation and guidance on conducting successful plan of care meetings with your patients.
My Questions & Goals
MY QUESTIONS & GOALS is a trifold brochure-style resource with a checklist of statements and questions that patients can address with their care team, as well as some open ended questions to help patients set their own goals and determine what is most important to them. Patient experts have shared that they had a lot of questions when they began dialysis. They were so overwhelmed with the amount of information that they did not even know where to start or what to ask—this was the driving force for this patient checklist brochure.
Patient Subject Matter Experts (SME’s) and care partners also shared that many times lab numbers are not the first concern of a patient, but if staff can shift the focus to quality of life issues (having energy, feeling better, etc), then patients will be more receptive. Since the questions may be different for patient just starting dialysis and those who are “existing” patients there are two versions available.
- Exploring Patient Engagement in Plan of Care and Policy and Procedures
- Staff Ideas to address Barriers to Participation in POC
- My Kidney Kit