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The One Patient One Plan Journey

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Nancy Pilon

on 8 October 2014

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Transcript of The One Patient One Plan Journey

The Nurse, Physician/Psychiatrist and Social Worker meet and review:
reason for admission
admission documentation
patient goals
admission RAI-MH and CAPS

At the Admission Conference, based upon the patient goals' and the information from supporting documents, a mini team is selected and invited to the first Mini-Team Meeting within the next 3 days.
The Mini Team Check-in involves the mini team and the patient, but need not include all team members (e.g. MRP) for all meetings. If the primary or secondary nurse is not available, the assigned nurse attends. Formal & informal supports can be invited.

The main goals of Mini Team Check-in are to:
1) Identify and celebrate any progress in the goals
supporting personal and clinical recovery
2) Plan the patient’s next steps and the required staff support
3) Indicate if goals have been achieved
4) As goals are achieved, establish new goals as required
Getting the Patient's Needs
As soon as possible, the nurse will obtain information
about the patient's likes and dislikes
care preferences
de-escalation preferences
visitors and contact information
Complete the RAI-MH
The nursing staff completes the admission Resident Assessment Instrument - Mental Health (RAI-MH) within 72 hours of admission
From this document, the first Clinical Assessment Protocols (CAPS)will be generated.
The Admission Conference
Discharge & Transition
The Mini Team collaborates with formal community supports throughout hospitalization, but this intensifies closer to discharge. This may be facilitated via onsite visits, video/teleconferencing, LOAs and/or follow up supports alongside the patient to achieve successful community tenure.
This deliberate investment is made to ensure good hospital and community links to best match the patient’s needs and wishes.
As the patient gets closer to discharge the final goal(s) being addressed in the Mini Team Check-ins will be addressing the transition back to community.
Considerable discharge planning will occur in these final Check-ins.
When the patient arrives...
Assign the Primary Nurse

Complete the Mental Health Admission tool

Complete the Kardex

Complete the Admission Care Plan

The One Patient One Plan Journey

First Mini Team Meeting
One Patient One Plan Development is initiated.

The main goals of One Patient One Plan Development are to:
1) Review the patient’s recovery goal
2) Identify the patient’s strengths
3) Establish mini goals required to reach personal and clinical recovery goals

Mini goals are prioritized according to the patient’s preference and clinical presentation through a collaborative approach. Only 3 are worked on at one time.

The Mini Team will define how success will be measured, the actions needed by the patient and staff members and a target date in achieving each mini goal.

Review and updated (if necessary) the anticipated discharge date and destination.
A copy of the One Patient One Plan Development document is provided to the patient or SDM
Mini Team Check-in
Mini Team Updates
Mini Team representatives meet with front line staff with the goals to:
1) provide information regarding mini goals and the individualized strategies/steps that impact patient care
2) to gain feedback and updates from front line staff regarding patient presentation that may impact care planning

Rounds occur on the unit and is a quick grouping of front line staff and mini team members. The logistics regarding when the rounds take place and how many patients are reviewed each meeting will be stipulated in each units’ standards
The Discharge Summary form is used to communicate with formal community supports (e.g. receiving facility or outpatient service)
the accomplishments of the patient and
the patient’s future goals in the community.
It will also include a transition plan suggesting effective support strategies to enhance the successful discharge and transition to community.

The Leave Smart form is completed in collaboration with the patient or substitute decision maker. This form is intended to be used by the patient or substitute decision maker upon discharge.
On my way...
Prior to the Mini Team Update the mini team members will work collaboratively to complete the RAI-MH. Mini Team Updates occur quarterly, or more frequently if required
The main goals of the Mini Team Update are to:
1) Identify and celebrate progress in personal and clinical recovery over the last 3 months
2) Compare previous and recent RAI-MH assessments
3) Indicate any changes to personal or clinical
recovery goals
4) Discuss discharge readiness
5) Plan next steps and the required mini team to
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