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Change in Condition Monitoring

The Change in Condition protocol was originally developed to support a Joint Research Study with Harvard Medical School, ClearCare, and Right at Home to determine whether early observation and intervention of changes in condition would lead to reduced hospital readmission rates. As a direct result of participating in the three-year study, Right at Home (Northwest, Oak Harbor, Mt Vernon) adopted the protocol as a best care practice and has ever since embraced it as a critical component of our mission to improve the quality of life of those we serve.
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Our Care Associates (professional caregivers) form the foundation of the Change-in-Condition protocol, as they are on the front lines of our client’s daily health monitoring. They are specially trained to spot critical changes in condition that could indicate a deteriorating health situation. These changes could be in the way a person walks, eats, drinks, sleeps, behaves, or could be a change in their physical condition such as skin color, texture, or sore.

Having spotted a change in our clients’ behavioral or physical condition, our caregivers are given an opportunity to report it at the end of their shift through our clock-out system that prompts the caregiver to give specifics about the changes and automatically alerts our Care Management Team.

The Care Management Team’s objective at that point is to verify the change and to prevent the condition from worsening. Once alerted, the client’s dedicated Care Manager will follow up with the caregiver, client, family member, POA, and/or health professional, as appropriate. Early alerts lead to early intervention and treatment and ultimately reduce the need for hospitalization.

The client’s Care Manager will then re-assess the client’s care needs and integrate any changes into a revised Care Plan. All of the client’s caregivers are briefed on the revised Care Plan and given special care-specific training, if needed. This closes the loop and ensures that everyone is properly informed and supporting the our clients new needs and situation.

Examples of Change-in-Condition Monitoring in Action

Caregiver rolling up sleeves of client

  • Our Care Management Team was alerted to a change in condition from a caregiver regarding the client having a 'hot spot' on the back of her feet. We were able to suggest that the family put a pillow under the client’s feet while she was sleeping, preventing a pressure sore from forming.
  • Our Care Management Team was alerted to a change in condition from a caregiver letting us know that the client was struggling in breathing; the client’s dedicated Care Manager went to visit him in the home and decided that he should be taken to the hospital. We got him there; and we were able to stop bronchitis from developing into pneumonia.
  • A Change-in-Condition alert that a client appeared confused and disoriented resulted in the client being seen by a doctor and treated for a Urinary Tract Infection (UTI).
  • A client with multiple days of loose stools that would have caused dehydration if left untreated, was given remedial treatment as a direct result of the Change-in-Condition Protocol.
  • Using the Change in Condition Protocol, one of our Care Associates alerted the Care Management Team that a new sore had appeared on the client. The client’s primary care physician was consulted over the phone and an over the counter cream was recommended. As the client was bedridden, a member of our Regional Operations Team picked up and delivered the cream to the client’s home so that it could be applied immediately.

5-Step Change-in-Condition Protocol

1. Our Care Management Team and all our caregivers are thoroughly trained on:

  • The Five Change-in-Condition categories
  • Observation and reporting procedures

2. Systemized prompting at end of shift:

  • Our phone-based clock-out software prompts caregivers to note any changes-in-condition

3. Reporting:

  • All caregiver responses logged (both digital and audio, if given)
  • An observed Change-in-Condition are reported to our Care Management Team

4. Verification:

  • The client’s dedicated Care Manager calls or visits client to reassess and verify the change in condition

5. Action:

  • RAH communicates the Change-in-Condition with the client care partners:
    • Family
    • POA
    • Social Worker / Discharge Planner
    • Case Manager
    • Primary Care Physician
  • Care Manager revises the Care Plan with inputs from the client’s care partners
  • Caregivers are briefed on the Care Plan changes and given additional training, as required

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