Medical Hemp

SN

cloudmd_newest_simply_connecting_LOGO_HEADER-01

Medical Hemp Care Plan

Disease Process

  • Surveillance
    • Assess and verify that patient and patient's legal representative (if any) and/or HIPAA authorized representative received written notice/document of patient's rights and responsibilities in a language the patient understands at SOC visit or by the second visit. Assess overall mental status related to alertness, orientation, and cooperation.
    • Assess emotional status: e.g., anxiety, depression, agitation, delusions, hallucinations, other.
    • Assess for behavioral manifestations of mental health illness; e.g., noncompliance with medications, social isolation, etc.
    • Assess sleep/rest pattern.
    • Assess substance use/abuse.
    • Evaluate and document response to medication and other therapies; re-administer depression-screening tool as needed.
    • Assess (since the last visit or encounter) if patient experienced S/S outside target or goal range (via reported symptoms, symptom logs, telehealth), if changes in plan of care and for overall perception of how condition is being managed.
    • Assess (since the last visit or encounter) if the patient used the ER, Hospital or unplanned physician office visit.
  • Teaching, Guidance and Counseling
    • Provide contact phone numbers and who to contact during evenings and weekends for symptoms/concerns.
    • Provide teaching techniques and strategies that enhance and promote health literacy (improved knowledge and compliance with care requirements).
    • Evaluate knowledge of S/S to report to RN/Therapist or Physician and those that need immediate medical attention. (Refer to Zone/Red Flag Plan). Use Teach Back Method to determine comprehension. Ask patient to repeat IN THEIR OWN WORDS.
    • Instruct to keep a log of episodes of worsening mental health condition and to include what is experienced and the events leading up to and surrounding the event.
    • Instruct on steps to take if patient's depression worsens.
    • Instruct on self-monitoring and management activities related to condition/disease process and actions to take with abnormal findings. Instruct on definition of depression and treatment goals (i.e., it effects physical well being, it is common, has physical causes, is treatable, and it is not the person's fault).
    • Instruct on causative factors of mental health condition.
    • Instruct on the importance of adherence to prescribed treatment regimen for depression (especially medication) to prevent exacerbation.
    • Instruct on effects of stress on disease process.
    • Promote/instruct on adequate nutrition, exercise, elimination, sleep/rest pattern and physical comfort.
    • Evaluate compliance with self-monitoring activities and appropriate follow-up for abnormal findings.
    • Evaluate ability to manage health status independently.

Test/Treatment

  • Treatment, Procedure
    • Perform procedure to obtain lab specimens as ordered.
    • Administer procedure/test/treatment as ordered.
    • Perform blood draw for medication levels as ordered.
    • Identify/confirm mental health drug levels are within therapeutic range, as applicable.

Medications

  • Surveillance
    • Assess (ask to see all medication & supplements) whether correct medications/supplements are in home. Review with patient/caregiver and reconcile medications, identify medication issues, make corrections and emphasize changes in regimen. Leave up-to-date medication profile and schedule in the home.
    • Assess for medication effectiveness/symptom control, side effects, compliance, other issues and for medication changes, review and update medication profile (reconcile medications) as needed.
    • Assess for S/S of drug toxicity/interactions (tremors, muscle stiffness, tics, dizziness, weight gain, agitation, involuntary movements).
    • Assess history of medication compliance and relationship to exacerbation of depression.
    • Assess attitude toward taking prescribed medications with standardized tool, e.g. HOGAN Drug Attitude Inventory.
  • Teaching, Guidance and Counseling
    • Instruct on purpose, action and side effects and how to monitor effectiveness of one or two medication/supplements and how and when to report medication problems.
    • Instruct on strategies to improve medication self-administration (pill box / medi-planner / med pre-fill) and simplification plan to support a manageable system and compliance.
    • Instruct on why it is important for current healthcare providers (including pharmacies) to have a complete list of medication/supplements; and why it is recommended to use one pharmacy.
    • Evaluate knowledge of the importance for a realistic plan for refilling medications before running out and evaluate if the patient/caregiver has a plan in place.
    • Evaluate and update medication profile with patient / caregiver and evaluate knowledge of actions, doses, side effects and times of medications to continue following discharge.
    • Evaluate and ensure current list of medications is left in home before discharge from services.

Nut/Hyd/Elim

  • Surveillance
    • Assess nutritional/hydration status and dietary/fluid intake.
    • Assess urinary function/status.
    • Assess gastrointestinal (GI) status for nausea, vomiting, diarrhea, constipation, fecal impaction or incontinence.
  • Teaching, Guidance and Counseling
    • Instruct on use of diet log, if appropriate.
    • Instruct to obtain and record weight weekly and when to report gain or loss.
    • Instruct on use of nutritional supplements and need to obtain approval from physician before taking, if appropriate.
    • Evaluate compliance with diet/fluid requirements.

Activity

  • Surveillance
    • Assess current activity and tolerance levels, ability to perform ADLs/IADLs, and level of assistance needed.
  • Teaching, Guidance and Counseling
    • Instruct on appropriate activity level.
    • Instruct on and promote activities to enhance physical function.
    • Instruct on importance of maintaining consistent exercise/activity schedule, give examples of exercises that are allowed.
    • Evaluate compliance with activity schedule.

Safety

  • Surveillance
    • Assess safety of home environment, for falls or injury and for other safety issues or precautions, and recommend modifications or instruct as appropriate.
    • Assess for weapons.
    • Evaluate ability to control impulses for self-harm.
    • Assess for correct/safe equipment use including assistive devices used in transfer activities.
    • Teaching, Guidance and Counseling
    • Instruct on procedures to take in the event of a natural disaster (fire, hurricane, tornado, etc.), evacuation plan.
    • Instruct on basic home safety precautions to prevent injuries/falls.
    • Initiate contract for safety or safety plan if necessary.
    • Instruct on and provide emergency plan to put in place during times of crisis.
    • Provide crisis intervention for high-risk situations.
    • Instruct on principles of Standard Precautions (proper handling/disposal of items coming in contact with body fluids).
    • Instruct on use of equipment or assistive devices for transfer activity.
    • Evaluate compliance with home safety precautions to prevent injuries/falls.
    • Evaluate compliance with Standard Precautions.
    • Evaluate compliance with safe use of equipment or assistive devices, instruct as needed.
    • Evaluate ability to maintain care/safety in home environment.

Psychosocial

  • Surveillance
    • Assess patient/caregiver psychosocial, emotional, coping, alertness and sleep status.
    • Assess barriers to care (cultural, financial, cognitive, caregiver, environment, other), and identify plan to address barriers, and implement action plan and involve patient in action plan.
    • Assess ability to purchase necessary medications, supplies, food, etc., needed for treatment.
    • Assess level of anxiety and coping skills or measures used to reduce anxiety.
    • Assess for feelings of hope for the future.
    • Assess family's attitude toward depression.
    • Assess ability to focus on strengths and abilities to maximize coping skills.
    • Evaluate need for spiritual support and if needed, contact appropriate clergy.
    • Assess motivation toward achieving an increased level of functioning.
    • Evaluate perception of progress toward addressing primary concerns and goals for care.
  • Teaching, Guidance and Counseling
    • Encourage maximum participation in treatment plan, and allow choices when possible to enable him/her to maintain a sense of control. Support verbalization of feelings, concerns and fears using motivational interviewing. (Motivational interviewing focuses on exploring and resolving ambivalence and centers on motivational processes within the individual that facilitate change) Encourage patient to write in a journal expressing thoughts and reflections daily.
    • Instruct on use of positive coping strategies (i.e., writing down and/or talking about concerns, relaxation - music, favorite TV show, doing enjoyable activities, etc.).
    • Instruct on importance of identifying and avoiding stressful situations.
    • Evaluate readiness to make behavior changes using behavioral activation techniques (replacing negative avoidance behaviors with new rewarding behaviors. This increases a person's positive reinforcement and reduces negative reinforcement.) Provide practical assistance and assist with problem-solving.
    • Instruct on hazards of social isolation.
    • Promote social support activities and relationships (i.e., identify/mobilize a support person(s) such as family, friends, support groups, visitors, and confidant).
    • Evaluate compliance with planned behavior changes.
    • Evaluate effectiveness of social support activities and relationships on depression management.
    • Provide positive reinforcement for progress made in coping/managing with condition.
    • Evaluate adaptation to disease/condition management into daily routine.

Interteam/Community

  • Surveillance
    • Assess use of social service programs.
  • Care Management
    • Instruct on, review plan of care including disciplines, visit frequencies, discharge plan and support involvement of patient/family in plan of care.
    • Provide the patient/caregiver written care planning instructions, based on the signed Plan of Care, to keep in the home within 5 days of Initial Assessment.
    • IF POST-INPATIENT, Instruct on importance of scheduling and attending physician follow-up appointment within 7 days of inpatient discharge.
    • Identify barriers and assist in making and attending appointment(s) or provide phone numbers and time frames.
    • Provide opportunity to practice and role play questions for PCP/ specialist in preparation for follow-up visits or next scheduled visit.
    • Instruct on the importance of a Personal Health Record (PHR), its components, and the need to share with all healthcare providers.
    • Evaluate need for and/or initiate case communication or documentation of communication.
    • Assess for next physician appointment (Date).
    • Evaluate plan of care including visit calendar with patient/caregiver and identify if changes are needed.
    • Provide patient/caregiver assistance in application of benefits.
    • Instruct on community resources to access in emergency situations.
    • Instruct on community resources and support groups that can assist in maintaining positive health behavior, meeting long-term care needs and evaluate ability to access resources.
    • Evaluate knowledge of and agreement with discharge plans.
    • Initiate plan for obtaining resources needed to meet functional and physical needs, if recommended.
    • Initiate request for referral to psychiatrist, counseling, as needed.
    • Initiate referrals to Alcoholics Anonymous, Al Anon and Alateen, as appropriate.
    • Provide community resource planning: including education, referral, advocacy and linkage, if recommended.
    • Evaluate and update patient's Personal Health Record (PHR) with changes in medications, diet, activity, allergies, s/s to monitor, etc.
    • Provide counseling for long-term planning and decision making, if recommended.
    • Evaluate plan to access community/family support for long-term care needs, as appropriate.
    • Provide information/assistance on placement to long-term care facility to help manage mental health condition.
    • Evaluate compliance with counseling/follow-up care.
    • Initiate referral to community support group of interest at or before discontinuing services.
    • Instruct on how and why to reorder or obtain supplies, medications, equipment and lab tests.
    • Instruct on importance of follow-up with physician/other services