(d) Standard: Coordination of care. (1) The HHA must integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness, the coordination of care provided by all disciplines, and communication with the physician.
As I travel the state to visit client agencies and communicate with client agencies in other states, I am frequently met with the statement “we don’t have to do 60 day summaries anymore!!!”. Well, in name and in name only, this is true. But, be warned agency owners, administrators and Supervising nurses… whenever Medicare seems to say you no longer have to do a certain thing, best to look for the two things that replaced it!
The requirements for coordination of care are more stringent. Surveyors are actively looking for coordination of care. (Note: Communication with the physician) For example: one agency was cited for no proof the CASE CONFERENCE was faxed to all prescribing physicians. The RN clearly documented the names of the patient’s cardiologist, pulmonologist and pain center. However, there was no proof the CASE CONFERENCE was faxed to all the listed physicians. (Suggestion from surveyor was to upload the fax confirmations into the system). What does this mean? Having a case conference in your software will no longer meet the requirements of coordination of care.
Another change savvy agencies are making is to ensure all clinicians and providers are listed by name and with credentials on the CASE CONFERENCE. This includes all therapists, aides and agency nurses who cared for the patient. In addition, the name of the patient’s PHC agency, wound care center or pain center needs to be listed. Some interpretations indicate Meals on Wheels should even be on the case conference. Note the regulation above says “coordination of care provided by all disciplines”.
When reviewing the regulations for the plan of care and changes to the plan of care, note the requirement to address what patient change in condition interferes with the patient achieving their goals and being discharged. A simple and accurate to address this requirement at recertification would be to copy and paste the goals from the plan of care and address these specifically.
For example: The goal “patient’s wound will heal by end of the episode” (Noted in case conference) Goal partially met. Wound is smaller in dimensions 4.0×2.5×2.0 at SOC now 2.0×1.0x0.5. Patient requires additional nursing visits to perform complex wound care which patient/cg are unable to perform.
Addressing each goal specifically will guide the CASE CONFERENCE and indicate continuity of care and compliant coordination of care
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