need up-skilling and supervision in administration of certain complex procedures until appropriate skills are attained support of informal and formal carers in their role as carer delivering a palliative approach to patients with life-limiting or threatening conditions supported by the specialist palliative care team and psychosocial support, as required. Refer to the Tier One Community Health, Transitional and Support Services service specification. and Wellness Education Information, Specialist Community Nurses have an important role, in the short term, in Education and sharing their specialist knowledge and skills as support for nursing staff in Advice Aged Related Residential Care facilities. Evaluation The Service Provider will: monitoring and undertake and document a formal reassessment against the care plan or assessment treatment goals, based on evidence and within time frame, using assessment tools as appropriate. For Service Users with acute needs, assessments are undertaken at each interaction, weekly or at one month whichever is the more appropriate to safely meet the needs of the Service User if the Service User stays within the Service, undertake a reassessment for Service Users with long term conditions six weeks following commencement of service provision and at least every six months thereafter to monitor the effectiveness, acceptability and appropriateness of continuing the provision of the Service where progress is different from expected, make changes to the Service care delivery plan and update referrer and the Service GP User’s User’s document demonstration of achievement of desired outcomes account for utilisation of consumables account for Service User contact activities e.g. telephone versus face to face contacts. Life - long For life long service provision, refer to the Tier One Community Health, service Transitional and Support Services service specification. provision The Service provider will: End of life care engage in and utilises an end-of-life pathway programme, such as guidance according to the written management /care plan collaborate in developing a systematic district approach to end of life care implement end of life care in non-specialist settings. Provision of The Service provider will provide equipment for eligible people of all age loan equipment groups who have been assessed as needing DHB funded short-term loan of (for personal equipment for the following reasons: health and disability to allow people with personal health and disability needs to remain at need). home, where appropriate to provide equipment for people to meet their assessed needs as an interim solution whilst awaiting long-term loan equipment. Note: Following a needs assessment, the Ministry of Health funds or contributes to the cost of equipment and modifications where a person with a disability meets specified criteria.
need up-skilling and supervision in administration of certain complex procedures until appropriate skills are attained support of informal and formal carers in their role as carer delivering a palliative approach to patients with life-limiting or conditions supported by the specialist palliative care team and psychosocial support, as required. and Wellness Education Refer to the Tier One Community Health, Transitional and Support Services service specification. Information, Education and Advice Specialist Community Nurses have an important role, in the short term, in sharing their specialist knowledge and skills as support for nursing staff in Aged Related Residential Care facilities. Evaluation and assessment The Service Provider will: undertake and document a formal reassessment against the care plan or treatment goals, based on evidence and within time frame, using assessment tools as appropriate. For Service Users with acute needs, assessments are undertaken at each interaction, weekly or at one month whichever is the more appropriate to safely meet the needs of the Service User if the Service User stays within the Service, undertake a reassessment for Service Users with long term conditions six weeks following commencement of service provision and at least every six months thereafter to monitor the effectiveness, acceptability and appropriateness of continuing the provision of the Service where progress is different from expected, make changes to the Service User’s care delivery plan and update referrer and the Service User’s GP document demonstration of achievement of desired outcomes account for utilisation of consumables account for Service User contact activities e.g. telephone versus face to face contacts. Life - long service provision For life long service provision, refer to the Tier One Community Health, Transitional and Support Services service specification. End of life care guidance The Service provider will: engage in and utilises an end-of-life pathway programme, such as according to the written management /care plan collaborate in developing a systematic district approach to end of life care implement end of life care in non-specialist settings. Provision of loan equipment (for personal health and disability need). The Service provider will provide equipment for eligible people of all age groups who have been assessed as needing DHB funded short-term loan of equipment for the following reasons: to allow people with personal health and disability needs to remain at home, where appropriate to provide equipment for people to meet their assessed needs as an interim solution whilst awaiting long-term loan equipment. Note: Following a needs assessment, the Ministry of Health funds or contributes to the cost of equipment and modifications where a person with a disability meets specified criteria. monitoring threatening
t2specialistcommunitynursingservicesservicespecificationmarch2015.docx