The Iowa Veterans Home offers an interdisciplinary care planning process for residents and their families. The ultimate goal of the interdisciplinary resident care conference (IRCC) team is to achieve and maintain the resident's optimal physical, psychosocial, and functional status while minimizing dependency. Upon admission, the social worker discusses the interdisciplinary care planning process with the resident and/or family.
The interdisciplinary team consists of:
- Primary Care Provider
- Registered Nurse
- Social Worker
- Recreation Therapist
Other professionals such as clergy, physical therapists, occupational therapists, and drug/alcohol abuse counselors may contribute to the care-planning process.
The care planning team, based on assessment of the resident’s individual needs, will develop an interdisciplinary plan of care. The care plan is initiated during the resident's admission and is continuously refined throughout the resident's stay. It is the right and responsibility of the resident and/or family to participate in the care planning process.
The care plan addresses:
- Anything that adversely effects the resident's health, comfort, and/or environment
- Anything that causes the resident concern
- Anything that requires attention to diagnostic (needs more study), therapeutic (needs treatment), or educational (needs teaching) nature of the resident's need
Appropriateness of the plan of care and progress on identified goals and approaches is reviewed at least quarterly and upon a significant change in the resident’s condition.