Care Planning and Coordination of Care: Revisions in the New Home Health Medicare Conditions of Participation


Nurse helping patient on a walker

Previous blogs have mentioned CMS' focus on the Triple Aim: Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and reducing the per capita cost of health care. In a review of the updated home health Conditions of Participation (CoPs), this theme continues.

Standard §484.60 "Care planning, coordination of services, and quality of care" establishes the expectation of individualized, patient-specific care plans as an element of quality services, including conformance to physician orders, and coordination of care using an interdisciplinary care team approach. The idea is that by assessing the patient's individualities, keying in on factors that play a part in their acute illness or exacerbation(s), and then creating a plan of treatment specific to these areas, the quality of care and outcomes will be increased.

The care planning standard alone may well change the way agencies handle the plan of care formation. Currently, in many agencies, the assessing clinician performs the initial and comprehensive assessment, and another person creates the orders and goals, and finalizes the plan of care for the patient. Another common practice is the use of "canned" orders and goals with little or no personalization for individuals. The updated conditions make these processes outdated and risky.

Take, for example, a congestive heart failure (CHF) patient who is referred for home health skilled nursing services. Currently, CHF patients often get the same treatment plan: "SN [skilled nursing] to instruct on disease process of CHF; action, dosage, side effects of medications; and importance of daily weights". In the new CoP environment, the assessing clinician would need to concentrate on this patient's knowledge gap deficits; socioeconomic, cognitive, or other factors that may have bearing on the patient's recurring illness; and frequent visits to the emergency department. These clues would help the assessing clinician formulate a plan of care and set of goals that focuses on this particular patient's needs from home health, and differentiate cases when hundreds or thousands of patients who have CHF do not need skilled home health services.

The updated Conditions of Participation also encourage the patient's participation in his or her care by requiring their goal for care be documented. By having a conversation with the patient, the assessing clinician can determine if the patient's goals are realistic given their diagnosis and course of treatment, and if not, communicate this information to the physicians while attempting to assist the patient in setting realistic goals.

Coordination of care is another important part of quality in the home health agency, and is also tied to the Conditions of Participation. While surveyors currently review for evidence of coordinated care, it is one of the most frequently cited aspects of care. The new home health Conditions of Participation mandate an Interdisciplinary team concept, which requires each discipline involved in the patient's care attend meetings wherein each discipline presents their unique insights and discusses the patient's progress toward goals. The Interdisciplinary team approach your agency takes is not mandated by CMS, and therefore agencies can choose the model they are most familiar with, if desired. Coordination of care with the physician(s), team members, patients and caregivers creates an environment where progress is easily measured and insights are shared. These measures increase the patient's quality of care, involvement and their satisfaction.

By incorporating the changes outlined in the Conditions of Participation for home health agencies related to care planning and coordination of care, agencies will be able to measure the patient's progress toward their individualized goals more easily. These measures will also ultimately increase the potential for better star ratings and home health compare scores.

The use of a software platform that allows easy, minimally invasive point of care documentation will allow a straightforward implementation of these and other standards of the Conditions of Participation. Axxess' mobile platform, which seamlessly integrates with the AgencyCore solution and has offline capabilities, allows the clinician to spend more time interacting with the patient while using a device that is second nature to them – their smart phone or tablet. Let us show you how to use our mobile technology and its features today to meet the standards of participation.