Home Care Team Plan

Home Care Team Plan is the first item of the HT Care Plan group. It is one page with the 25 sections of the home care team plan, in the plan document's order and with its section names: Patient Profile, Person Centered Preferences, Goals and Outcomes, Functional Assessment, Weekly Coverage Plan, Care Hours Calculation, Daily Routine, Medication Plan, Clinical Services, Wound and Skin Plan, Monitoring Parameters, Nutrition and Hydration, Mobility and Fall Safety, Cognition, Communication, and Behavior, Team Roster, Role Assignment Rules, Communication and Handoff, Safety and Infection Control, Emergency and Escalation Plan, Service Interruption Plan, Equipment and Supplies, Administrative File, Shift Documentation, Review and Revision, and the Team Readiness Checklist.

This first version reads what is already there and changes nothing. Each section is filled live from the page where that information already lives: the Patient Profile, the Emergency Plan Card, Insurance & Devices, Important papers, the Day named after the patient, Prescriptions, the care targets on Health Tracking, Menu & Kitchen, the Care Team, My Home Team, the weekly schedule and the shift checklists on Home Team management, Supplies and the rest. Nothing is copied into the plan, and opening the plan never edits any of those pages.

Every section starts closed, with its number, its name, one line about what was found and a chip: Filled from what's already there (green), Partly filled (amber) or Not started (grey). A section reads Not started when nothing has been entered for it yet, or when it is a part of the plan the app has no home for yet, such as Goals and Outcomes, the Functional Assessment, Care Hours, the Wound and Skin Plan, the Service Interruption Plan and Review and Revision. Those sections say what they will hold and list anything already logged that relates to them, such as therapy goals or open shifts.

Open a section to see its rows in the plan document's table form. The Medication Plan, for example, shows each current prescription as Medication and Strength, Purpose, Dose and Route, Time, Who May Give or Assist, and Special Instructions, with a dash where the app has no field yet. Under the rows, each source reads Found in, the page's name, and when it last changed and by whom where the app records it, with Open the full page to go there and make a change. Still to add lists what the plan will add later, and a short second list names the fields a Medicare or Medicaid plan lists for that section.

When two places say different things, such as the date of birth on the Patient Profile and on the Emergency Plan Card (or an organization's patient record), the home address on the card and on the profile, or the pharmacy on the card or a prescription and the pharmacies on Prescriptions, the plan shows both values side by side with where each came from, marked These don't match. Fix the one that's wrong. The plan never picks one.

The top of the page counts the sections filled, partly filled and not started, and the readiness line. When a hospital discharge is logged with Log a call or visit on the Care Team page, the plan starts with the day the patient came home. The Team Readiness Checklist shows the plan document's 15 statements, each as Met, Not met or Can't tell yet with a link to the section that would meet it; a statement reads Met only when the information in the app shows it. Print the plan prints every section opened.

The account owner and caregiver-role accounts open the plan. Family-role accounts, friends, care-team logins and the agency office do not see it in this first version. The plan is the family's working copy; it does not replace a doctor's orders or a licensed professional's plan of care.