References:

Documents:

Family Home Visiting

The purpose of the Evidence-based Standardized Care Plans for Community Dwelling Elders is to provide a shared care plan for elders and providers in order for elders to remain at optimal health and wellbeing, and live safely in their homes/communities. Problems included in this guideline were identified by international stakeholders, including home care providers and scholars. Interventions were synthesized from the literature and validated by providers, scholars, and consumers. The interventions are intended to be non-overlapping across problems, and to build a comprehensive, holistic plan of care for those problems deemed applicable by the consumers and members of the health care team.

Monsen, K.A., Foster, D. J., Gomez, T., Poulsen, J. K., Mast, J., Westra, B. L., Fishman, E. (2011). Evidence-based standardized care plans for use internationally to improve home care practice and population health. Applied Clinical Informatics, 2, 373-384. doi:10.4338/ACI-2011-03-RA-0023

Monsen, K.A., Westra, B.L., Paitich, N., Ekstrom, D., Mehle, S.C., Kaeding, M., Abdo, S., Naratajan, G., Ruddarraju, U. (in press) Developing a Shared Personal Health Record for Elders and Providers: Technology and Content. Journal of Gerontological Nursing.

Omaha System Problems:

• Abuse
• Caretaking/parenting
• Circulation
• Cognition
• Communication with community resources
• Health care supervision
• Income
• Interpersonal relationship
• Medication regimen
• Mental health
• Neglect
• Neuro-musculo-skeletal function
• Nutrition
• Pain
• Personal care
• Residence
• Respiration
• Sanitation
• Skin
• Social contact
• Substance use

Date of most recent guideline revision:

December 2011

Encoded by:

Karen A. Monsen, Bonnie L. Westra

Encoded date:

December 2011

Contributors:

Karen Monsen, Washington State Community Health Leadership Forum

Sources:

HealthEast Care System, University of Minnesota School of Nursing (Minnesota), Buurtzorg Nederland (Almelo, Holland), Nurse Maude (Christchurch, New Zealand)

References:

Documents:

Community Dwelling Elders