Sample Care Area Assessment (CAA) for Return to Community Referral
Resident Information:
- Name: Michael Johnson
- ID: 862543
- Date of Assessment: YYYY-MM-DD
- Room Number: 305
Assessment Team:
- Primary Nurse: Lisa Hamilton
- MDS Coordinator: Thomas Wright
- Social Worker (SW): Angela Davis
- Physical Therapist (PT): Omar Jenkins
- Occupational Therapist (OT): Emily Clark
Care Area Assessed:
- Specify the care area: Return to Community Referral
Step 1: Triggered Care Areas
- Triggered by Michael's expressed desire and readiness to consider returning to independent living in the community following a period of rehabilitation for a hip fracture.
Step 2: Review of MDS 3.0 Findings
- Michael has shown significant progress in physical rehabilitation and has reached a level of independence in ADLs that supports a potential transition back to community living.
Step 3: Detailed Assessment
- Clinical findings: Assessment of Michael's physical recovery, including mobility and self-care capabilities, confirms his potential for successful community reintegration.
- Review of medical records: Notes on Michael's rehabilitation progress, previous living situation, and social supports available in the community.
- Consultations with interdisciplinary team members: Discussions on necessary preparations for discharge, including home safety evaluations, outpatient therapy needs, and community support services.
- Resident and family interviews: Gather insights on Michael's support system, personal goals, and concerns about returning to independent living.
Step 4: Problem Identification
- Identified challenges include ensuring Michael's home environment is safe and accessible, coordinating continued outpatient therapy services, and connecting him with community resources for additional support.
Step 5: Care Planning
- Goal: To develop a comprehensive discharge plan that supports Michael's successful transition to community living, addressing his healthcare needs, home environment modifications, and social support systems.
- Interventions:
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- Conduct a home safety evaluation and recommend necessary modifications to facilitate mobility and daily activities.
- Arrange for continued outpatient PT and OT to support ongoing physical recovery and independence.
- Coordinate with community agencies to provide Michael with access to supportive services, including transportation, meal delivery, and social engagement opportunities.
- Develop a follow-up plan with the SW to monitor Michael's adjustment to community living and address any emerging needs.
- Educate Michael and his family on available resources, emergency preparedness, and strategies for maintaining health and well-being in the community.
- Responsible Staff: SW, PT, OT, Nursing Staff
- Timelines: Immediate initiation of discharge planning with targeted completion date prior to Michael's anticipated discharge, ensuring all services and supports are in place.
Step 6: Interdisciplinary Team Review
- The team collaborates on Michael's discharge plan, ensuring a coordinated approach that leverages the expertise of each discipline to facilitate a smooth transition to the community.
Step 7: Resident and Family Engagement
- Engaging Michael and his family in the discharge planning process ensures they are informed, prepared, and confident in the transition plan, fostering a sense of empowerment and ownership over the process.
Step 8: Monitoring and Reassessment
- Short-Term: Weekly check-ins by the SW post-discharge to assess adjustment, address any concerns, and modify the plan as needed.
- Long-Term: Monthly follow-up for the first three months post-discharge, then as needed, to ensure Michael's continued well-being and satisfaction with community living.
Documentation and Signatures:
- Signature of MDS Coordinator: Thomas Wright, Date: YYYY-MM-DD
- Signature of Primary Nurse: Lisa Hamilton, Date: YYYY-MM-DD
- Signatures of other interdisciplinary team members involved.
IDT Meeting Follow-Up:
Scheduled Date: YYYY-MM-DD to review the effectiveness of the discharge process, discuss any challenges encountered by Michael post-transition, and identify opportunities for improvement in future community reintegration efforts.