Resident Medical Officer

CCF Clients' Admission Process - Active participation in the clients' admission process at the Continuum Care Facility, from a medical, holistic & continuum care point of view, understanding the needs of the client and the scope of services needed.
- The admission process at Sukino Continuum Care Facility (CCF) star
- The admission process at Sukino Continuum Care Facility (CCF) starts with a facility visit/ connect where either the client/ representative or the clinical details including all available medical reports are provided to the medical officer.
- The client if present is evaluated or the provided information is reviewed and additional medical information is sought as appropriate to assess and analyze the latest clinical condition of the client prior to admission at CCF.
- If the medical information is inadequate/ incomplete, a discussion with the primary/ referring clinician/ team is requested and conducted.
- A pre CCF admission assessment is conducted which helps the medical officer to further understand the healthcare needs and the clinical status of the intended client.
- An internal review with our internal board can also be sought to discuss various medical intricacies.
- The physician subsequently recommends for CCF admission if the client meets the criteria, or recommends appropriate measures/ optimizations' to safely provide care for our clients at CCF.
- If the client does not meet the clinical criteria to be safely managed at the CCF(s) that would need to be explained to them with appropriate documentation thereof.

Initial assessment & plan of care - Detailed initial assessment & holistic continuum plan of care anticipating the duration of stay at Continuum Care Facility, interact with nutritionists, physiotherapists and work as a team with nursing and paramedical personnel.
- Once the client is admitted to the CCF, they need to be clinically examined, assessed, document and implement the "Initial Assessment with instructions for care" within 4 hours of the clients' admission to CCF.
- The client will need a detailed plan of care within 48 hours of admission to CCF about the clinical pathway in CCF, Medication Reconciliation with detailed instructions covering the following but not limited to it.
- Nursing plan of care covering the clients' medical issues, indwelling lines, catheters, drains, implants and devices.
- Dietary guidelines in consensus with the nutritionists.
- Instructions to caregivers.
- Rehabilitation plan in consensus with the therapy team to define the goals of care.
- Planned Investigations.
- Anticipated specialty opinions/ review.
- Counselling the client/ their representatives.
- Anticipated barriers for care towards discharge and

Daily care of clients - Daily care of clients at Continuum Care Facility and periodic updating of the relatives or representatives of the clients or other specialty doctors involved in the management of the admitted client conforming to regulatory and accreditation bodies. The primary role will be in monitoring and charting a plan of care for the rehabilitative, recuperative and palliative care clients.
- Clients need to be monitored daily & additionally on SOS basis by each doctor with inputs from the concerned client, their family members/ representatives, caregivers, nursing personnel, team of physiotherapists, nutritionists etc. and recommend appropriate measures to enable the intended rehabilitative and/ or recuperative and/ or palliative/ end of life care with special emphasis on acute and chronic aspects of their care needs.
- Relevant investigations can be requested as per the care plan and appropriate specialty opinion/ review can be sought on a need/ request basis. The Centre head of operations would facilitate the same with the consent from the client / their representatives.
- Clinical updates would need to be provided to their primary clinician on a regular/ need basis.
- The medical notes would need to be documented in the SOAP (Subjective, Objective, Assessment & Plan of care) format conforming to regulatory bodies and National Accreditation Board for Hospitals & Healthcare Providers (NABH).
- All clinical discussions with the client/ their family/ representatives would need to be documented in detail in the physician's notes.
- All measures would need to be taken to ensure the safety of the clients adhering to the International Patient Safety Goals (IPSG).
- A subset of clients would qualify for palliative/ end of life care. Such clients would need relevant compassionate care with emphasis on comfort and the philosophy of care will be to maintain & facilitate a transition towards comfort measures only without additional treatment or escalation to advanced care in consent with the family/ representative.

Family meetings - Conduct regular family meetings with the multidisciplinary team.
- 1st Family meetings are to be conducted as soon as possible and within 48 hours of the Client's admission to update the stakeholders of