Care Plan ideas for quarterly visits

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I've started working as a case manager almost a year ago, now I work from home and see my members once a quarter unless there's a change in condition. I'm having a hard time with care planning since I'm not directly involved. All my members are in nursing facilities. I don't want to have a goal of say "blood sugars in range with finger stick accuchecks", because I'm not there to know except once a quarter. Looking for suggestions or resources that I can make good acheiveable goals for my members that are realistic and not outside of my control. Thanks!

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

The goals should be patient centered and not nursing centered. So, the goal is the patient's goal. If the patient does not have a the ability to make decisions, then the goal is the guardian's goal. You can always use your nursing judgement and help guide the patient and/or family and/or guardian to come up with a realistic goal, but the goal is theirs and not yours. Thinking this way, should make it easier on you. :)

By the way, are you able to visit your members at least once a quarter? If so, I highly recommend doing that before doing an assessment of the patient and discussing your findings with patient/family/guardians/whomever. Hope that helps. :)

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Perhaps you could have an A1C results as a goal instead of accuchecks. Or ask the facility to print you a copy of the glucose levels.

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Specializes in Care Coordination, Care Management.

Who are you case managing for? The NFs?

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