The goal of Phoenix Home Care’s clinical team, under the guidance of a physician, is to develop a plan of care to treat each patient’s medical condition. The plan of care focuses on the patient which includes the family, and/or caregivers, and is supported by the Phoenix Home Care team. The plan of care includes assessment, goal setting, treatment and discharge. Phoenix Home Care improves patient outcomes by the use of evidence based practice to ensure the quality of care provided.
Step 1: Assessment
At the Physician’s order, a Phoenix clinical liaison will conduct a patient consultation at the hospital or skilled nursing facility. During this consultation, the clinical liaison will meet with the patient, family, and/or caregiver to plan a successful transition to Phoenix Home Care’s services.
Home Care Admission
A Registered Nurse, Physical, Occupational, and/or Speech Therapist will perform a detailed assessment of the patient at his/her home environment.
Step 2: Goal Setting
Our team of Registered Nurses, Physical Therapists, Occupational Therapists, Speech Therapists, and Medical Social Workers will work with the patient, family, and/or caregiver to develop a care plan using evidence based practice to manage their conditions. Individualized short and long-term goals will be established to assist each patient in returning to their prior level of function.
Step 3: Treatment
Each clinician will take part in the complex recovery process:
Registered Nurses will monitor vital signs, medications, wounds, lab draws, etc., and all medical conditions following evidence based practice and physician orders.
Physical Therapists will facilitate restoration of motor function following evidence based practice and physician orders.
Occupational Therapists will improve activities of daily living and cognitive skills following evidence based practice and physician orders.
Speech Therapists will enhance communication and speech, as well as evaluate and treat swallowing disorders following evidence based practice and physician orders.
Medical Social Workers will assist, as needed, to provide information about available community resources and help patients remain in their home.
Home Health Aides will help, as needed, with personal care and bathing.
The clinician will educate the patient, family, and/or caregiver in all aspects of care.
Step 4: Discharge
Discharge from Phoenix Home Care will occur when the patient meets short and long-term goals and/or reaches maximum rehabilitation potential. The clinical team will empower the patient, family, and/or caregiver to continue the rehabilitation process to achieve optimal function.