Advanced Care Planning in Home Health Services

Planning for emergencies and end-of-life care isn't exactly fun, but it is necessary. Advanced care planning lets you create treatment plans based on each patient’s preferences so their loved ones aren’t left with tough decisions. As a home health caregiver, you can take steps to plan your patients’ care while they're still healthy and able to make decisions about their care. 

With WorldView's document storage system, you can store and share advanced care plans and attach them to health records to make it easy for your care team to access these plans when needed. 

Understanding Advanced Care Planning

So, what is advanced care planning (ACP)? It's a term used in the medical field that involves discussing your patient's preferences for future medical treatment with their family and legal professionals in case they become seriously ill and can't express their wishes. For example, if a patient is in a serious accident and left in a vegetative state, advanced care planning helps ease the burden on their loved ones by providing the medical team with written documentation of their wishes. 

It goes beyond directives such as life support and other life-saving treatments. Advanced care planning also includes setting up a living will and designating a power of attorney to make medical decisions on the patient's behalf when they can’t. 

As a caregiver, you can work with your patients to set up advance directives and other important documents. You can explain treatments and interventions with your patients so they can make informed decisions about their care. 

The Role of Advanced Care Planning in Home Health

By nature, home health care is patient-centric. You're caring for your patients in an environment where they feel most comfortable, helping them live independently and supporting their recovery. If you also provide hospice services, you help patients live out their final days comfortably at home. 

Advanced care planning provides guidance for you and your team in unpredictable situations. Instead of making assumptions about a patient who can’t advocate for themselves, you have a clear plan for their care. For example, suppose you’re treating a patient with chronic hypertension who suffers a severe brain bleed. Advanced care planning would outline whether the patient wants to be kept on life support if recovery seems unlikely.

Having these discussions early and documenting them helps improve patient satisfaction by making sure their wishes are respected. 

Key Components of Advanced Care Planning

Advanced care planning involves discussing care options and patient preferences. You work with your patients to create advance directives and a living will. The terms "advance directive" and "living will" are often used interchangeably, but they serve different purposes. A living will provides instructions to a patient's family about the care they wish to receive. An advance directive, on the other hand, appoints a person to make decisions on the patient's behalf if they can’t. 

When working with a new patient, ask if they have an advance directive or living will in place. If the patient has a chronic illness or is approaching the end of their life, take the time to walk them through their condition and discuss end-of-life treatment options and planning. 

You can then guide them through various legal forms, such as a Medical Durable Power of Attorney, which designates someone to make decisions on the patient's behalf. If your patient decides to create a living will or a healthcare proxy, explain how to have it witnessed and notarized to make sure it’s legally binding. 

Implementing Advanced Care Planning in Home Health Services

It’s best to approach patients early about setting up advance directives. You can introduce the topic during a health checkup or by bringing up similar cases. Let your patients know they can update their living will or advance directives whenever they want — they’re not bound to a treatment plan. 

Once your patient has set up their advanced care plan, collect copies of the documents, scan them, and attach them to the patient record. This way, caregivers can access them quickly in case of an emergency. 

Challenges and Solutions in Advanced Care Planning

Common challenges that arise during advanced care planning include limited resources and a lack of coordination among caregivers. If your patient is being treated for a chronic illness, they may have a large team of physicians and home health caregivers. To successfully execute advance directives and living wills, every member of your patient’s care team needs to be familiar with their wishes. 

In some cases, your patient’s wishes may go against your caregivers’ training. As a caregiver, you are trained to save lives, but if you’re treating a patient with a “do not resuscitate” directive, you must respect the directive and not intervene. Regular training and open communication can help your staff manage the psychological impact of not taking action during emergencies. 

Conclusion

Advanced care planning helps your caregivers make critical decisions when patients can’t speak for themselves. With these plans in place, your team knows exactly what to do to provide excellent patient care in any situation. Encourage your patients to actively participate in their treatment by creating advance directives, living wills, and other relevant documents. 

Make it a habit to discuss setting up plans with your patients and collect their electronic documents. Use WorldView’s electronic document management solution to attach legal forms to a patient’s records and physician’s orders and easily share them with everyone on the care team. Doing so will help ease the burden on the patient's loved ones and enhance the quality of care. 

Set up a demonstration today to learn how WorldView can help you manage your patients’ advanced care plans. 

   

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