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Transdisciplinary Skilled Care Planning DVD

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Transdisciplinary Skilled Care Planning DVD

Each transdisciplinary care plan is an individualized plan based on the patient's need and potential for improvement at the start of care. An optimal care plan is developed in collaboration with the patient and caregivers. It consists of the patient's health care problems and related expected outcomes, as well as plans for skilled interventions. In this video, we follow the same patient a patient named Leroy and build a plan of care for him, using the goal-writing techniques that are taught.

You Will:

  • Utilize assessment findings to create an effective care plan.
  • Write goals that are functional, objective and measurable.
  • Use evidence-based and objective evaluation tools to formulate goals that support the need for skilled services.
  • Link interventions to impairments and goals
  • Write goals in patient-centered language.


Minnesota HomeCare Association Rehabilitation Council: This council supports best practices for speech, physical and occupational therapist in the home health setting. They also share information regarding assessments, interventions and processes. 

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