Care+ KanTime Plan of Care Guide (Part 1)

Care+ KanTime Plan of Care Guide (Part 1)

Table of Contents

Plan of Care Purpose

Building out the Plan of Care

Updating Client Details

Creating Plan of Care

Plan of Care Purpose

The Plan of Care (PoC) is a critical document for your office as it structures and explains what & why we are providing care for the client, while prioritizing and understanding their specific needs. We start with the information collected during the client intake process and expand on that by including their clinical/medical details, relevant contacts, goals, and even track their fall risk, level of independence, cognitive abilities, pain levels, and sleep profile.

By consistently maintaining and updating the PoC this helps your office and caregivers understand what we are working to achieve with the client through each visit, and how we can continue to address the client’s evolving needs through the customized card that we offer. It is also important that the Plan of Care is updated and new versions are generated based on your state requirements, so your office is prepared for any audits and state surveys that occur.

Building out the Plan of Care

After the client intake is completed and they have been onboarded as a client, this information will be saved to their profile and can be accessed by going to the hamburger icon  and selecting ‘Interview Info’.

Updating Client Details

Within the client’s Interview Info there will be the following subtabs:

To update these sections, select the specific tab and then choose the green ‘Edit’ button and enter your changes. Once added, you will hit the ‘Save’ button and receive a confirmation message saying ‘Updated Successfully’.

The Fall Risk, ADL-IADL, GPCOG Screening, Pain & Sleep tabs all have an asterisk which indicates they have scoring fields. These scores can be used to run reports on your clients and see any changes, whether it be progression, regression, or stabilization of those areas and help you determine next steps such as reviewing the type of service being received by the client and updating their Plan of Care. This information can be shared with the client’s healthcare provider for further evaluation as indicated.

Below is an overview of each tab that can be included in the PoC:

• Intake – stores details captured during Intake process
• Social History – capture background & summary within Client’s Story and their social background
• Important People – record client’s contacts such as family, friends, neighbors, power of attorney, etc.  
• Providers – stores physicians involved in the care of the client and their pharmacy information
• Goals – identify short term & long term goals for client as well as other potential services and observations
• Safety Evaluation – indicate safety of client’s home and living spaces; provide suggestions for client and caregivers to consider in maintaining a safe home environment
• Supportive/Assistive Devices – capture devices being used and provide details on how to utilize for client’s care
• Medications – provides details of the client’s current & discontinued medication and vital sign monitoring
• Conditions – provides a list of all the client’s conditions and details of their specific situation
• Symptoms – record client’s symptoms regarding Allergies, Communication, Cardiac/Respiratory, Skin, etc.
• Nutrition – capture client’s dietary & liquid preferences, considerations, and restrictions
• Fall Risk – record the client’s risk of falling; provide suggestions for client and caregivers to consider in preventing any falls or accidents
• ADL-IADL – Activities of Daily Living & Instrumental Activities of Daily Living to observe a client’s level of ability in each area
• GPCOG Screening – General Practitioner Assessment of Cognition to screen for potential cognitive impairment
• Pain – record client’s level of pain and include details as well as ways that it is being addressed
• Sleep – capture client’s sleep profile including hours, routine, quantity, and quality of sleep

On the Clients section of HomeShare you can find forms to help you provide an effective intake & consultation experience as well as resources to implement initiatives for wellness, dementia care, and quality management while building and managing your client’s Plan of Care.

Creating Plan of Care

To create a Plan of Care, search the client’s profile and choose the Plan of Care tab > POC versions. You can also go to the client’s Interview Info tab and then follow the same the steps below.

From the Hamburger menu select the ‘Create POC’ option.

You will then choose from the following sections to generate this client’s Plan of Care. If this is your first time creating the PoC, the details from the client Intake will be captured in the documented sections. If other information or changes need to be added, refer to the previous section for ‘Updating Client Details’.

A message will appear that the ‘Plan of Care Generated Successfully’ and the latest version will be added to the list.

There will also be a record of the Date Generated and who it was Generated By, if required for any audits or state surveys.