Sample Team Meeting Agenda

(Panel Name) SASH Team Meeting Thursday, December, 15, 2013

Follow-up for SASH TeamMeeting Thursday, Nov. 17th

Name: John Doe

Action Plan/Follow-up/who responsible: 11-18-11Suzanne will refer John to the CHT which now covers Dr. Smith’s office for nutrition counseling.

  • CHT (Andrea) e-mails Suzanne when John Begins. Meals on Wheels now deliver Mon-Fri food for diabetes.
  • Updates-John broke his leftankle. Doing well. Nurses keeping up with check in rounds. Suzanne has done grocery shopping and picking up meds at pharmacy.

Name: Jane Jones

Action Plan/Follow-up/who responsible: Suzanne will contact Wendy regarding the plan to meet with the PACE MSW and the possibility of participation in a support group.

  • Suzanne sent e-mail to Wendy11-18-11 to have the PACE social worker, Mary Giancola, meet with Jane with the intention of helping her identify what unmet needs are overwhelming to her. Shewill also help Jane discern how to judge when it may be the appropriate time to consider nursing care. She will also explain the financial implications associated with that decision.
  • Bobpassed away. (spouse)

Name: Liza Minelli

Action Plan/Follow-up/who responsible: Maria will call family (Goldie) re appointment with MD; will ask about additional help with hygiene. Maria will call MD and discuss concerns with MD.

Suzanneor Wellness Nurse will discussneed for additional help with hygiene with Liza. Possibility of reintroducing Stephanie [homemaker] (assuming family cannot afford private help) to Liza for assistance.

Paula will check notes regarding earlier determination re eligibility for CFC.

  • 11-18-11 Received fax copy from Maria S. (VNA Office) for the Montreal Cognitive Assessment (MOCA) that Maria W. did on Liza Minelli. It was put in Liza Minelli’s Blue folder.
  • Maria faxed Montreal Cognitive Assessment to Dr. Smith. Maria speaking with niece, Goldie.
  • Suzanne notifiedGoldie(Niece) to schedule Dr.s Appointment with Dr. Smith-(Dec 7th.)
  • Lizaagrees to let Stephanie back in to help her shower. Stephanie will begin on Thursdays, Dec. 15th.

Name: Judy Garland

Action Plan/Follow-up/who responsible: 11-18-11 Suzanne Starts med check in rounds everyday and contact daughter to discuss med dispenser. 11-17-11 Nurse Liz Coleman, concern with Judy not taking her Meds. Found on numerous visits that Judy forgets. Suggest daily check in’s and or med dispenser.

  • Suzanne /daily check ins for AM meds. One puff of inhaler. Daughter suggest hiding inhaler.

Name: Maya Angelou

Action Plan/Follow-up/who responsible: Suzanne contact family to get housekeeping set up. Suzanne contacts (PCA) Stephanie to work with hygiene. Shower 2 times a week; check in 3 times a week.

  • Spoke with Son about cleaning apartment. Mother has a lot of stuff, stubborn to rearrange. They are there every week to clean. They will speak to Mom to have cleaning service each week. $16. I have not heard back from family. PCA says family doing a better job of cleaning.
  • Maya on CSC AL list, Eric says near to top.
  • Wendy, can PACE provide services?

Additional New Participants

Name: Lynn Redgrave

Wed. Dec 7th: Lynn sent out by ambulance because blood glucose over 400 and blood pressure high. Daughter notified, met Lynn at ER.

Reason for 911.

  • Over medicate.

Lynn given CT at ER visit and sent home.

  • Diagnosis: Brain Atrophy.

Daughter needs help and assistance with what to do.

  • Lynn calls the police several times a day and night, stolen meds, storm windows and car.
  • Calls daughter all times of the night.
  • CVAA referral call in on Friday, December 9th.
  • Suzanne does MED checks each AM.
  • Wellness Nurse/Sarah and daughter in contact.

Name: Bette Davis

Friday, December 9th: Anxiety attacks-has seen Doctor-prescribed medication-anxious about jury duty-request to contact Maria.

  • Suzanne called court found out that Bette has been excused for jury duty.Bette very happy and relieved.
  • Bette still request need to see Maria- Maria has been contacted.

Name: Jaclyn Smith:

Jaclynhas difficulty communicating with community, 2 people in particular (Farah Fawcett, Kate Jackson).

  • Suzanne and Maria met with Jaclyn to work with her in setting up intervention with Farah and Kate.
  • Maria and Jaclyn continue visits.

Jane Doe:

Jane recently diagnosed with Liver Cancer. Son Jack now working with VNA/Hospice. Prognosis determined, 2 to 3 months.