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.

Southern Web SupportExploring Coordination of Care Scenarios
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