Prior to a plan of care being developed, a Nurse Case Manger visits the home/living facility of a client to conduct a comprehensive assessment.  This assessment evaluates the client’s health and psychosocial needs by reviewing their history, as well as current, physical, mental, emotional, social and Spiritual health.  Once completed and needs are identified, a determination is made as to what areas may need to have outside assistance to facilitate a safe environment.  If care is being provided at the time of the assessment, this is also evaluated and discussed to assure needs are being handled appropriately and to determine where this fits into the care plan.

All medical conditions are reviewed along with any cognitive challenges that may be present to determine what emotional (psychosocial) ramifications these may have. The availability of family support and the working dynamics are also assessed.  Further evaluation of the following is performed:

  • Need for personal care (toileting, oral care, bathing), environmental hygiene (housekeeping, laundry), and adequate nutritional intake (grocery shopping, meal prep, safe food management).
  • Need for assistance understanding and ensuring home financial management is appropriate and timely. (check book management, bill paying, postal needs)
  • Need for interpretation of medical conditions and facilitation of communication and coordination between members of the health care team and family.
  • Need for household oversight (maintenance) and safety within the environment including a home safety evaluation, ambulation safety evaluation, DME safety evaluation and the development of an emergency plan.