Assess mood, engagement, and the psychosocial effect on the skilled plan; implement non-pharmacologic support and structured re-engagement.
Provide management and evaluation of a plan complicated by psychosocial factors and coordinate social services and the team.
Teach and evaluate the discharge caregiver to competence with return-demonstration; escalate a caregiver-capacity gap.
Teaching / training (to mastery)
Teach the resident coping and engagement strategies and the value of the skilled plan, and involve them in goal-setting, with teach-back.
Teach the discharge caregiver the specific care they must provide (medications, transfers, device or wound care, warning signs) to competence, with return-demonstration.
