MUSKOKA HEALTH LINKS COORDINATED CARE PLAN / (patient information)

MY INFORMATION

Name: DOB: Age: yrs.

Gender: HCN: Version Code:

Address:

Private Home: Yes No Retirement Home: Yes No Other:

Home Phone: Mobile Phone: Email:

Preferred Method of Communication:

Preferred Language: Interpretation Required: Yes No

Marital Status: Single Married Divorced/Separated Common-law Widowed

Occupation:

Source of Income: Employed Ontario Disability Support Program (ODSP)

Ontario Works (OW) Pension Family Ext. Health Benefits

Other:

My Main Caregiver:Name: Relationship:

Phone:Email:

My Legal Decision Maker:Name: Relationship:

Phone:Email:

Power of Attorney Personal Care:Name: Relationship:

Phone: Email:

Other things I want you to know about me:

MY CARE PLAN COORDINATOR

Name: Contact Information: Role:

MY CARE TEAM

Name: Contact Information: Role:

Name: Contact Information: Role:

Name: Contact Information: Role:

Name: Contact Information: Role:

MY CURRENT HEALTH

Health Condition(s)*: Complications:

Stable Unstable Stability (frequency of treatment change):

*Includes physical, mental health and social determinants)

MEDICATIONS

My known, current medications / Last updated: / Last updated by:
Date of last medication reconciliation: / Performed by:
My last medication change was: / It made me feel:
Aides I use to take my medications: / Challenges I have taking medications:
Drug name / Strength / Route / Frequency / Reason / Pharmacy / Start date / Change date / Prescriber

Community Pharmacy: Pharmacy Telephone:

Medication Storage: BottlesDosette Blister Package

Medication Set-up: Self Family Pharmacy

Concerns with medication adherence:

Reconciliation Completed: Yes No

Date Completed:Completed by:

MY SAFETY NET

My long term concerns are:

My immediate concerns are:

If I experience (signs/symptoms/situations):

I will (action to take):

If I am having problems coping or my caregiver is feeling overwhelmed, our plan is:

MY ADVANCE CARE PLAN

Questions to Guide Discussion / My Advance Care Plan
"Do you have an Advance Care Plan?"
(If yes, where is it located?)
"What do you understand about advance care planning and/or advance directives?"
"Can you tell me what kinds of decisions you have made about your future care?"
"One of the most important decisions we encourage all adults to make is to think about who they would choose to make decisions for them if something happened and they were no longer able to communicate their decisions. Do you have someone you might consider asking to take on this responsibility?"
"We have some information here that I'd like to give you that will help you and your family/close friends to start talking and learning together."
(Provide TC LHIN Advance Care Planning Workbook, Ministry Guide and Power of Attorney for Personal Care document).

MY GOALS

Category / Goal / Action/Who
Assistance with understanding my care instructions:
Are you having any difficulty understanding your care instructions?
What would make it easier for you?
(Provide examples of assistance available)
Assistance with my medications:
Are you having any difficulty getting, organizing and/or taking yourmedications?
What would make it easier for you?
(Provide examples of assistance available)
Assistance with my nutrition:
Are you having any difficulties getting and/or preparing nutritious food?
What would make it easier for you?
(Provide examples of assistance available)
Assistance with getting through the day and night:
Are you having any difficulties getting through the day and/or night?
What would make it easier for you?
(Provide examples of possible solutions)
Assistance with my mental health:
Have you been having any concerns about your mood(or thinking/remembering)?
Have others expressed concern about your mood (or memory)?
What would make it easier for you to feel better (or manage day to day)?
Assistance with safe living:
Are you having any challenges with living safely day to day?
What would make it feel safer for you?
(Provide examples of possible solutions)
Assistance with controlling my substance use:
Are you having difficulties controlling your smoking(or drinking/drug use)?
What assistance would you find helpful right now?
(Provide examples of assistance available)
Assistance with supporting my circle of care:
Do you have any concerns about those who help you on a regularbasis?
What assistance might be helpful to reduce these concerns?

OTHER AREAS REQUIRING ASSISTANCE

Immediate Needs:

Tests/Follow up Appointments / Date Booked / Primary Care to Book

CARE PLAN

CCAC Services / Goals for Care/Frequency / Start Date
Back Up Plan
Equipment / Instructions / Delivery Date
Community Services / Goals for Care/Frequency / Start Date

TCC – Client Coding – Muskoka Health Links

<:O:AdminMgmt/Forms/Nursing/Muskoka Health Links Coordinated Care Plan
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