Care Coordination is Essential for Home Health and Hospice Agencies to Ensure the Quality of Care for Patients

Care Cordination in Home Health

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According to the Medicare Conditions of Participation, care coordination is a frequent source of citations in home health surveys. While the plan of care is usually the number one issue for citations, care coordination is usually just a little behind.

Optimally planned coordination is advantageous for patients, providers, and payer organizations. Enhanced quality of care, patient safety, reduced readmissions and ER visits, and cost-effectiveness is some of the many advantages of successful care coordination. Even though the advantages are evident, many Home Health and Hospice Agencies need help optimizing coordination. According to Medicare’s Conditions of Participation, care coordination is one of the most frequent citation areas on Home Health surveys.

Management of Care under the HHVBP Program

It is important to collaborate with organizations to raise care coordination endeavors in preparation for the approaching national implementation of the Home Health Value-Based Purchasing (HHVBP) program when the consequences for home health are more serious. It is noticed that one of the objectives of the nationwide VBP implementation is to unite and coordinate care. To be successful in HHVBP, aligning with Outcome and Assessment Information Set (OASIS) measures will be crucial. The total performance evaluation of an agency under HHVBP will be based on claims-based and OASIS-based measures and five components of the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey. Patient comprehension of communication and team discussion are two of those five elements. The HHCAHPS Survey will make up 30% of the agency’s total performance score, and this score will decide the agency’s payment adjustment for 2025. Since numerous home health agencies need help with low survey execution in this area, they are likely to have a similar result under HHVBP. Comprehensive home health staff training is critical to perform better under HHVBP.

Enhance Monitoring in Hospice Care Facilities

Hospice organizations must be aware of the need for care coordination. The Centers for Medicare and Medicaid Services (CMS) is increasing the focus on hospice inspections this year by instructing surveyors to pay particular attention to interdisciplinary care planning and coordination, as well as four core Conditions of Participation. Other important areas of basic surveyor training include patient rights, initial and complete examination of the patient, and Quality Assessment and Performance Improvement (QAPI). CMS has emphasized these topics in the surveyor’s basic training program this year and is providing accrediting organization surveyors with comprehensive instructions on reviewing care plans.

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Evaluating Interaction and Cooperation

Care coordination involves sharing patient information among those involved in the care process to provide safer and more efficient care. It is the monitoring of care through cooperation among personnel. Examples of care coordination may include formal case conferencing with the patient’s representative and routine interdisciplinary team meetings to map out roles and responsibilities and handle any obstacles that may impede the patient from receiving the needed services. Additionally, care coordination includes communication between the medical staff outside of regular meetings. For instance, the LPN and RN might chat about changes to the patient’s condition, such as weight gain or wound deterioration. Also, the physical therapist or occupational assistant might inform the clinician in charge of any updates. Surveyors will look for structured and unstructured care coordination forms to assess how well the care team communicates and functions together to ensure better patient care. Agencies should be ready for surveyors to closely inspect their operations, as there will be increased oversight concerning care quality and environment of care this year.

Recording Information on Patient’s Medical History in their Medical Files.

It should be evident in the medical record that the healthcare team adequately evaluates and attends to the patient’s needs, communicates data concerning the patient effectively, and then keeps track of changes and responds to them. An infringement typically boils down to someone not providing someone else with the relevant data so that the institution can offer the patient the appropriate care. Because services cannot be charged for the time clinicians spend away from the frontline, it may not be possible to have regular, devoted periods of care coordination. Care coordination should be built into the standard productivity of the institution. In each patient’s medical record, the team’s coordination should at least be indicated at the following times: 

  • Beginning of care
  • At the end of the monthly billing period, review to determine if there is a change in the focus of treatment.
  • If there is any change or problem in the condition of the patient
  • The two weeks it was preceding the date of recertification.
  • In the discharge planning process
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For more complex cases, coordination should take place more often.

Enhance the Management of Care

Here are a few ideas to aid in organizing care coordination. 

1. Schedule periodic care coordination meetings. In addition to conveying information about the patient to all involved parties, a gathering once or twice a month can help agencies build accountability. Agree on roles and responsibilities, monitor and follow up on any changes in patient needs or objectives, link the patient with local resources, and aid with the transition of care. 

2. Make sure to include all members of the care team. Organize interdisciplinary team meetings, and there “Everyone had input. If your agency needs help finding interdisciplinary meetings, arrange a secure video conferencing session. Virtual meetings are beneficial in times of staff shortages and hectic workloads. Participants should be encouraged to include home health aides in these meetings. They are truly the eyes and ears of the patient. 

3. Document all care coordination. In busy agencies, a lot of care coordination takes place throughout the day as clinicians work — but not all of it is documented. For instance, a quick call to consult with another care team participant about the patient must be noted in the medical record. If it wasn’t documented, it wasn’t done. 

4. Ensure that the documentation is entered into the medical record. An ex-surveyor of the Accreditation Commission for Health Care has a cautionary tale of an agency with notes showing close-to-perfect care coordination meetings. The clinical manager was new and doing an exceptional job of holding weekly meetings, discussing their patients, assessing issues such as falls and complaints, and keeping detailed notes in a binder for anybody to access anytime. Other than the binder, they had everything else in order. Yet, rules are rules, and there was no reference to any care coordination in the medical records, technically violating the agency’s care coordination requirements. “So we can’t just say that if it wasn’t documented, it wasn’t done,” said the surveyor. “We must add that if it wasn’t documented in the medical record, it wasn’t done.” 

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5. Share the documentation obligation. Overworked clinical managers need help to take on the documentation duty. It is suggested that agencies back clinical managers by giving some documentation tasks. Operations, schedulers, and some back-office staff members can take notes in conferences, follow up on equipment tracking, and more. 

6. Concentrate on follow-ups. Up-to-date agencies place a significant emphasis on follow-up, backed by procedures, requirements, and accountability. Although home health and hospice nurses don’t end their shifts with a report like in hospitals, they can create a similar follow-up attitude. When a patient is referred and has special equipment needs, a question arises, who is checking up to ensure the patient gets that equipment? When the equipment is supplied, is it documented in the medical record? Follow-up is always an essential element of care coordination, which surveyors will look at very closely.

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