I will echo those pieces said already from Patti and Diane, as well as will add that often we capture individuation in the pre and post death assessments, and IDG discussions as well. Due to the pieces Patti notes so well in her response, while a large number of folks are not interested in services, what we are able to capture in the chart in the assessments and early planning does speak to the work we are doing to prepare for the creation of more individualized/specific goals and interventions should a person wish to access services and supports. When we have been surveyed the variety and personalization seen in these assessments have been validated and affirmed as valuable and reflective of our efforts and readiness to do more.
For those that do accept support, there is a great deal of variety that then unfolds in care plans and goals therein, which gets right to what you were asking about. Our entire program provided intensive training sessions throughout the last year around care planning and we have seen all of our staff, including our bereavement team, greatly benefit from that. The problem statements, goal statements, manner of capturing patient/bereaved progression toward goals, and well written plans for next contacts has come so incredibly far! Our survey a month ago was deficiency free and on their exit they stated that our care plans were the best they had seen in the state. It was well worth the effort we put into those trainings to come to where we are now.
Joelle Osterhaus, MSW, LCSW, LICSW, ACHP-SW (she/her)
Hospice & Palliative Care Psychosocial Services Manager
Kaiser Permanente Northwest
Continuing Care Services
2701 NW Vaughn St., Ste. 140
Portland, OR 97210-5344
Cell Phone: (503) 312-0819
Main Office: (503) 499-5200
Fax: (503) 499-5535
CCS Social Work Sharepoint Site (internal use): https://sp-cloud.kp.org/sites/NWCCSSocialWork/Shared%20Documents/Forms/AllItems.aspx
CCS Bereavement Program Sharepoint Site (internal use): https://sites.sp.kp.org/teams/nwreg/NWAmbulatoryCare/CCS/Hospice/SitePages/BS.aspx
CCS Dept Sharepoint Site (internal use): https://sites.sp.kp.org/teams/nwreg/NWAmbulatoryCare/CCS/SitePages/Home.aspx
Hospice Volunteer Website: : https://www.kpnwvolunteer.org/hospice
kp.org/thrive
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