TABLE 2

Issues Related to Ongoing Monitoring of Home Care

1. Regular review of home care discharge plan to determine whether goals are being met or have changed
2. Child assessment
 a. Physical condition
 b. Appropriateness of current nursing care
 c. Developmental issues
 d. Advance care planning
3. Family assessment
 a. Strengths
 b. Problem identification
 c. Changes
 d. Family–provider communications
 e. Adequacy of current services
4. Financial
 a. Paperwork
 b. Policy benefit changes
 c. Family financial changes
 d. Adequate coverage
5. Equipment/supplies/medications
 a. Identification and tracking of current needs
 b. Prescriptions written
 c. Justification letters
6. Diagnostics ordered with appropriate interventions made, and referrals to specialists as needed
7. Follow-up appointments made
 a. To PCP
 b. To specialists
 c. Coordination of appointments and procedures whenever possible
 d. Communication with subspecialists in a timely way so that the child’s changing needs are being addressed