Assessment refers to a constructed, detailed, comprehensive understanding of our clients, including their healthcare needs, capabilities, weaknesses, bio-psychosocial, medical and spiritual assessment, client history, and a strengths assessment that cultivates and locates inner/external clients resources they can access and draw upon in themselves, their family system and home community.
Care Planning and Goal Setting
Planning encompasses the steps necessary to build a care plan that defines treatment goals, tasks, and actions needed to move towards goals and the motivation to carry out tasks.
Plan implementation is part of our clinical case management program where the plan of care with its varied.
Plan monitoring occurs throughout the entire process and is related to seeking ongoing feedback and conducting follow-up as necessary to how the treatment plan of care is being implemented and producing results.
Transitioning and Discharge
Transition and discharge is when a Grata House client is prepared to move across our healthcare continuum, depending on the client’s need for services. Our client is transitioned back home or through a step-down outpatient process.
Grata Clinical Case Managers maintain an on going relationships with all our clients with weekly zooms the first month back home and monthly outreach zooms/calls to reconnect on continued goals and referral resources if needed.