Home Health Plans of Care: A Guide to Success

It is said that if you fail to plan, you plan to fail. When it comes to patient care for home health agencies, this is certainly the case. Patient care plans are an important component of success for home health agencies. It is crucial that HHAs understand how to develop care plans that not only effectively manage patient care, but also meet CMS guidelines. The latter can be challenging due to changing CMS rules, including the new Conditions of Participation (CoPs) that were introduced in early 2018.

CMS requires that plans of care include specific information about the patient, including all diagnoses, mental and cognitive status, prognosis, functional limitations, and all medications and treatments. Plans of care must also outline safety measures to prevent injury, patient-specific interventions, patient and caregiver education, and goals and measurable outcomes that should arise as a result of implementing the care plan. When executed properly, plans of care can make the care process more efficient for both patients and providers.

The Importance of Patient Care Plans

While plans of care are required for Medicare reimbursement, they are much more than CMS “red tape.” Well-developed, individualized care plans can greatly improve patient experience and outcome. Plans of care function as an organized form to identify individual patient needs and monitor their progress throughout their time of care. The plans make it simple for all healthcare providers involved with a patient’s care to have a clear picture of their health history, their current needs, and the success of various interventions. Plans of care can be thought of as a roadmap, or set of instructions, for a course of action to be taken by all healthcare providers involved with a patient’s care.

Plans of care are a collaborative effort between multiple members of a patient’s healthcare team. It can be accessed by providers from different disciplines to see a patient’s health status and what interventions have been implemented so far, which means that patients can expect more consistent, efficient care. Providers also have the ability to make changes to a patient’s plan of care if goals are not being met or problems are identified. This ongoing maintenance of plans of care means that more patients are likely to see effective treatments being implemented and problems being identified earlier on in their care. Individualized care planning that makes care more efficient can also reduce costs for the HHA- it’s a win-win.

What Makes a Good Plan of Care?

A good plan of care will be able to identify the needs of the patient and set a clear path for managing their condition moving forward. An effective plan of care must:

1.) Identify the patient’s needs
2.) Address their current problems and a path to managing these problems
3.) Continually evaluate the patient’s progress and response to care

A Systemic Approach

To compose plans of care that can effectively guide patient care, it is good to break down the process of creating care plans into steps. This systemic approach provides a blueprint for the best ways to identify patient needs and provide them with care to meet their goals. The systemic approach includes:

1.) Conduct a comprehensive assessment of patient’s health
2.) Identify the patient’s problems and potential future problems
3.) Develop a plan of goals for the patient’s health and how to reach these goals
4.) Implement the plan
5.) Continually evaluate the plan and make changes as needed

The Assessment

Perhaps the most important step in developing a plan of care is the patient assessment, as the information gathered during the assessment process will determine the plan of care and its future success. Prior to the new HHA CoPs that were implemented in early 2018, the patient assessment was a simpler process. Formerly, home health nurses would conduct a patient assessment, then discuss their assessment and develop a care plan with a physician, and the process could be considered done. Under the new CoPs, the assessment process is much more comprehensive. Clinicians use data from a variety of sources involved with the patient’s care, and prepare documentation on the patient’s condition and how these conditions may affect health management. One of the sources clinicians use are data elements from the Outcome and Assessment Information Set (OASIS). OASIS is a CMS required document for all HHAs, and can help identify patient needs to be incorporated in a plan of care.

At the patient assessment visit, HHA employees will validate the information from the patient’s referral source that was included in the initial documentation. The combination of previously supplied information and data with information gathered during the in-person assessment will together be used to develop a patient’s plan of care. In certain cases, psychosocial assessments are also needed and an important part of the patient evaluation and plan development. This initial documentation, and the plan of care as a whole, should serve as support for why certain interventions were implemented. If the plan is developed and implemented correctly, an auditor should be able to look over care plan documentation and easily understand why certain interventions were selected.

Do Not Neglect Other Areas of Your Business

Comprehensive care planning is just one of the many elements of supporting a successful HHA that all home health care workers must balance. Between ever-changing CMS requirements and the need to deliver timely, high quality care to patients, managing a HHA can be very overwhelming.

While patient care should be the primary focus of any healthcare provider, it does make it easy to overlook other important aspects of the business. To stay on top of your HHA’s finances while focusing on aspects of patient care like care planning, it can be extremely beneficial to seek outside help. Liberty Consulting is an experienced firm specializing in home health and hospice services. They can assist your HHA with operations including billing, payroll, bookkeeping and accounting, and cost reports and tax returns. If you want to be able to put your all into patient care while keeping your HHA’s finances under control, without the stress of managing both, contact Liberty Consulting.

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