Exploring Coordination of Care Scenarios

Proper coordination of care is only possible if the entire interdisciplinary team caring for the patient works together.  This team must be proactive and collaborative in order to achieve its primary goal of enhancing patient outcomes through a course of interventions and a goal-oriented plan.  Only a comprehensive team that includes everyone across all disciplines can successfully treat the patient.  Physician(s), contractors, the clinical team manager, assistants, aides, patient caregiver(s) and representative(s), and the patient must be considered part of this team.  To better illustrate how an interdisciplinary team must work together to achieve excellent patient outcomes, we have provided a few different scenarios below.

Case Study #1 – Mrs. Jones

Mrs. Jones is admitted to home health with a primary diagnosis of Diabetes with peripheral neuropathy. To achieve the best outcome for her the following plan of action is documented and implemented:

  • Jones has SN, PT, OT and Aide ordered.
  • One of her comorbidities is CHF. She has had no signs/symptoms of CHF since her admission.
  • The PT / PTA are seeing Mrs. Jones for difficulty walking, muscle weakness and previous falls – partially caused by her peripheral neuropathy.
  • During the 3rd week of home health services, the PTA makes a visit to Mrs. Jones. This PTA has seen the patient on two previous visits.
  • Today the PTA notes that the patient is coughing, has more ankle edema and while walking with Mrs. Jones, the patient is more fatigued than on other days.
  • This is the first time that the PTA has noted these signs and symptoms in Mrs. Jones. The patient says that they started the day before.
  • The PTA knows that Mrs. Jones has CHF as a comorbidity, so he lets the other team members know this information via the communication notes in the EMR.
  • In order to prevent Mrs. Jones from having further symptoms without the physician being informed, the PTA contacts the RN Case Manager by telephone as well to report these signs/symptoms in the next hour.
  • The nurse has a visit ordered for this week. However, she moves it and makes a visit on Mrs. Jones that day to assess the patient and identify all status changes.
  • The nurse notes that what the PTA stated and documented is continuing for the patient; therefore, she calls the physician and reports these changes in the patient. The physician orders an extra dose of the diuretic that the patient is prescribed.
  • This coordination of care prevents Mrs. Jones from having a CHF exacerbation – with an ER visit or rehospitalization.

Case Study #2 – Mrs. Jones

  • In the 5th week of home health services, the Aide sees that the patient has a red area on the left buttock that wasn’t there on previous patient visits.
  • She documents this in the EMR note section to the team. Also, in her visit note she states this and that she reported this to the RN.
  • The Aide also calls the RN since she recognizes that this change in skin condition indicates that the nurse needs to know prior to her next re-synchronization of his laptop when he will see the note.
  • The RN acknowledges the conversation and her actions in the Notes section of the EMR.
  • The RN states that she will visit the patient the next morning.
  • She also asks the rest of the team members to ensure that the patient teaching on skin care, repositioning, and reporting any changes is done on each visit.

Keeping You Current on Coordination of Care

5 Star Consultants provides many ways for home health agencies to stay on top of industry changes such as the recently revamped CoPs dealing with coordination of care.  Care management between the interdisciplinary team has assisted numerous agencies in implementing much better communication, compliance with patient care/ clinical record documentation and increasing patient outcomes through care management models.  5 Star Consultants can provide remote and onsite consultation partnering with your agency in order to help you with your coordination of care to comply with the new CoPs and to increase your star ratings!

With our many training options and manuals, your staff can always be informed, ensuring that deficiencies and fines do not plague your HHA.  To learn more, please contact us at [email protected] or 866-428-4040.

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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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Work as a Team to Improve Patients’ Pain Levels and Experience Better Outcomes

Ensure all individual members of multidisciplinary teams work toward a common goal to ensure patients’ pain lessens throughout the episode.

When team members move in various individual directions to address pain, this decreases the chances that the patient’s pain will be lessened or eliminated by the end of the episode and beyond.  Improving your agency’s results on pain can help with its scores on Home Health Compare, 5-star ratings and value based purchasing.

At many agencies, employees don’t communicate well and the patient feels like the right hand doesn’t know what the left is doing.

To resolve this issue and achieve the best results on M1242 (Pain interfering with activity), the entire multidisciplinary team must have frequent, open communication and discuss team strategies.

During the conversations, it’s possible that one multidisciplinary team member might identify pain issues that can best be addressed by another discipline.

Open communication can occur with the help of electronic medical record (EMR) notes, conference calls with the team, voicemails set up for the multidisciplinary team and, of course, face-to-face meetings.  Detailed EMR notes will ensure there is good documentation in the clinical record, which is important in order to show compliance of coordination of care in the legal clinical record.  (See an example of a clinician’s thorough, detailed note at http://bit.ly/2ibym2Y.)

It is essential that necessary documentation such as follow-up assessments be shared among team members, but it’s also important that relevant information in visit notes, orders and reports be made available.

Don’t Overlook Aides, Contractors

When thinking about the importance of communication among multi-disciplinary team members, don’t forget about home health aides.  They often spend the most time with the patient and understand what the triggers are for the patient’s pain — such as if there are side effects of the pain medications.

Also, don’t overlook contracted services.  These service members are a big part of the team if, for example, they provide therapy for the patients.

In fact, the revised Home Health Conditions of Participation (CoPs), which largely take effect Jan. 13, 2018, enforce the fact that the aide and contracted services are a part of the interdisciplinary team.

The newly released draft interpretive guidelines for the CoPs state for §484.80(g)(4) that during interdisciplinary team meetings, all agency staff involved in the patient’s care must be present for and contribute to the discussion.

The aide is allowed to participate in person, electronically or by phone.

Ensure Effective Pain Management

  • Have every clinician perform a thorough pain assessment during every visit. During an initial pain assessment, ask the patient to describe past and current experiences with pain including: effectiveness of the methods used to manage the pain, both pharmacologic and non-pharmacologic; experiences with side effects and interactions; typical coping responses while having pain and what is effective; and what, if any, concerns the patient has about pain.

When documenting each pain assessment, the clinician should address pain characteristics including the onset, duration and location.

Detail where the pain is located, as well as associated symptoms.  List factors that help alleviate or exacerbate pain.  And explain the patient’s functional abilities with and without pain.

Within documentation, indicate why pain is high or low.  For example, did the patient forget to take her pain medication?

  • Ensure that coordination of care is continuous. This way the team can determine what kinds of treatment are effective and ineffective.  Some patients, for example, might like meditation or music therapy while others might not.

Don’t wait until the agency’s overall case conference to discuss strategies to eliminate or reduce a patient’s pain.  The team must talk whenever there is any issue or change, the patient isn’t making progress, or the patient has achieved a goal.

This should never occur less than weekly, but it can occur more often than that.  It can even be something as short as documenting: “The patient’s hip pain was at 7 today.  The patient stopped taking her pain medication due to wooziness.  The physician was notified and ordered a new pain med.  The patient will begin taking it tonight, and teaching about the possible side effects was completed.  PT will evaluate in the a.m. to see if the medication was effective.”

Note that the multidisciplinary team’s communication needs to be even more responsive if the patient’s pain issues are more urgent.

  • Include the physician(s) in discussions about pain. Talk about what the multi-disciplinary team recommends, and communicate frequently with the physician if interventions are ineffective.

Many teams don’t include the physician in discussions frequently enough.

The RN or therapist should communicate with the physician for status reports and requests of additional options for pain management treatment or to find pain medications and doses appropriate for the patient.

Among the other options available to help with pain: Ice, heat and ultrasound machines.  The physician also might approve of music therapy or meditation, for example.

Communications with the physician not only should be placed into physician orders and visit note documentation, but also must be communicated to the team in real time.

If you would like to discuss how we can assist you with the team approach to pain management, please feel free to contact us at [email protected] or 866-428-4040.

Source:  Home Health Line, Decision Health, December 4, 2017

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