Best Practices for Documenting Coordination of Care

On January 13, 2018 new CoPs (Conditions of Participation) were implemented, which included Condition 484.60 dealing with care planning, coordination of services and quality of care.  This new Condition combined 484.18 (Acceptance of Patients, Plan of Care, Medical Supervision) with 484.14 (Coordination of Care).  It is critical to accurately document coordination of care not only because if it is not documented it is not considered complete, but also it could result in your home health agency (HHA) being fined for deficiencies.  According to one surveyor, “The best way to avoid deficiencies, in my opinion, is to have clear documentation. If something was communicated, document what was communicated, specific date of the communication, who was the information communicated to and if a physician, what was the response.  Many times, I see vague descriptions or incomplete documentation.”

Coordination of Care Details

The coordination of care is comprised of several standards that involve not only communication between physician(s) and a patient, but also include communication with caregiver(s), representatives (if any) and HHA staff.  Below are the standards that are included in this Condition:

  • 6o(d)(1) G602 – Assure communication with all physicians involved in the plan of care.
  • 6o(d)(2) G604 – Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient.
  • 6o(d)(3) G606- 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 and the coordination of care provided by all disciplines.
  • 6o(d)(4) G608 – Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities.
  • 6o(d)(5) G610 – Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge.

Documentation of Coordination of Care

Now that we have covered the standards involved with the coordination of case, we are going to move onto best practices for documentation.

As mentioned above, the coordination of care documentation involves multi-disciplines; therefore, it is key not to act alone, but coordinate and collaborate as a team.  It can be challenging at times when interacting dynamically with a patient in his/her home environment with family or caregivers, but remember, proper patient care “Takes a Village”!

This documentation should include reports on the status of the patient, any changes in condition(s), symptoms and/or what was done.  The patient’s medical team is responsible for identifying issues and concerns related to his/her well-being; therefore, it is crucial to address every last one of these issues and concerns.  Documentation should be completed any time there is information to report about the patient.

In order to improve patient outcomes, it is important that everyone on the team is active, not passive.  Even encourage the team to think outside the box to improve patient outcomes!  Remember the patient is dependent upon the team; therefore, follow through and problem-solving are critical.

Any and all information should be placed in the email or notes section of the EMR (electronic medical record), which is shared with the team.  However, if an EMR is not available, secure HHA email can be used instead.

This documentation is to key illustrating the ongoing communication occurring between all the members of the team who are involved in the patient’s care.  It must provide a complete story of the patient.

Effective Interdisciplinary Care Coordination Results in:

  • Increased patient outcomes
  • Increased Agency outcomes
  • Increased customer satisfaction
  • Increased employee satisfaction
  • Increased Survey Success

The 5 Star Team is Here for You!

Our team of experts at 5 Star Consultants is always current on industry changes and with our many training options we can help ensure your team is up-to-date too.  To learn more about how we can help you, please contact us at [email protected] or 866-428-4040.

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