Alvarez explains that CMS expects greater communication and care coordination among providers, and has added a requirement that agencies have a Clinical Manager to assist with coordination. "Care conference and communication among team members is of great importance. Home health providers need to evaluate their current processes for care conferencing and regular communication between the interdisciplinary team members caring for a patient and revise as appropriate to meet this requirement," she adds.
In addition, care planning and case management will need to be more interdisciplinary than in the past. "With patients at the center, clinicians must collaborate on best practice measures to eliminate unnecessary duplication while ensuring effective coordination of services to meet patient needs," Alvarez says. Implementation of the new CoPs will encourage the realignment of care to a primary care team led by a registered nurse (RN) Case Manager (or licensed Therapist for rehab-only cases as applicable). The Case Manager is professionally accountable and responsible for the patients' continuity of care, and:
- Establishes therapeutic relationship with an individual patient/family
- Remains the Case Manager for the patient's entire length of stay
- Accepts responsibility for decision-making for the plan of care
- Identifies the patient's unique health needs and priorities, establishes an individualized plan of care, and communicates that plan to other members of the team
- Establishes plan of care and oversees the ongoing changes to the plan of care to meet patient needs and goals
- Is responsible for achieving clinical outcomes
Simione recommends the following strategies that home health providers can implement in preparation for these requirements:
- Evaluate current policies, documentation practices and process flows related to comprehensive assessment, care planning and coordination of services.
- Determine the process for collection of information about each caregiver's willingness and ability to provide assistance, availability and schedule. This includes incorporation of this information into the patient's care plan.
- As Case Managers, clinicians need to be knowledgeable of community, state and federal resources that may be available to assist patients and refer to Medical Social Work services as these needs are identified.
- Clinicians will need to use communication methods that encourage patients to participate in their own care and become real partners in decision-making.
- Many clinicians will need additional training in assessment and case management to meet the holistic patient assessment requirements in the CoPs and to be able to communicate and collaborate effectively with patients to discover their perceived strengths, goals and care preferences.
- Implement a true Case Management model to ensure care is effectively managed with efficient, effective and outcome-driven visit utilization, care coordination and care planning. Patient-centered care is achieved when the different disciplines work together to assess the patient's needs through true interdisciplinary teamwork.
Simione Healthcare Consultants understands that home health agencies want specific strategies will help them achieve compliance with the new CoPs, while demonstrating efficiency and effectiveness. Our expert consultants will work with your agency to evaluate the impact of these new requirements, conduct a CoPs Readiness Assessment for clinical operations, and provide staff training to support improvements in quality and efficiency for key performance measures.
Contact us at 844-215-8820 or www.simione.com/contact.
About Simione Healthcare Consultants
Founded in 1966, Simione Healthcare Consultants embodies a diverse group of business talent across the U.S. to provide accessible, cost-effective business solutions for the home health and hospice organizations. Key areas of expertise include operations, compliance and risk, finance, sales and marketing, cost reporting, information technology, and mergers and acquisitions. Simione supports performance improvement across the healthcare continuum, engaging agencies, hospitals, health networks for more effective delivery of home health and hospice care. More than 1,500 organizations use Simione's experts and tools to improve quality, reduce costs, and minimize risk to drive business performance.
Contact: Linda Wiseman
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SOURCE Simione Healthcare Consultants