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CoP Educational Series Part 8: Comprehensive Assessment and Care Planning

Posted on Thursday, July 13, 2017 8:20 PM

This post will introduce CoP changes and additions regarding the Comprehensive Assessment – 484.55 and Care Planning – 484.60.

Each patient in home health must receive and the home health agency must provide, a patient specific comprehensive assessment.  For patients that are Medicare beneficiaries, the home health agency must verify the patient’s eligibility for the home health Medicare benefit, including homebound status, both at the time of the initial visit and at the time of the comprehensive assessment.

The first two standards related to the comprehensive assessment have not changed with the revised CoPs. These standards include:

  • The initial assessment visit
  • The completion of the comprehensive assessment visit

As previous, the initial assessment must be completed within 48-hours and the comprehensive assessment must be completed within the 5-day window of start of care.  The requirement that an RN completes the comprehensive assessment except in therapy only cases is unchanged.

The contents of the comprehensive assessment visit have some additional requirements with the revised CoPs. Included in the verbiage is the requirement to include the patient’s current health, psychosocial, functional and cognitive status.   Assessing a patient’s psychosocial status refers to an evaluation of the patient’s mental health, social status and functional capacity to identify areas of risk around their social and/or psychological status. This will assist the home health agency in developing and implementing a patient specific plan of care and to identify unmet patient goals that may require further follow up with another health care provider. 

In addition, the patient’s strengths, goals and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the home health agency. Traditionally, the patient’s plan of care has focused on their deficits and the required treatment making the patient a passive recipient in their health care. The goal now is to assure home health agencies plan for and provide patient-directed care and in accordance with the physician orders.  

It is also required to capture the patient’s primary caregiver/s, if any, and all other available supports and their willingness and ability to provide care and their availability and schedules. The patient’s representative, if any, must be identified. 

Requirements regarding updating the comprehensive assessment remain intact. The comprehensive assessment must be updated:

The last 5 days of every 60 days beginning with the start of care date – unless there is:

  • An elected beneficiary transfer
  • Significant change in condition
  • Discharge and return to the same home health agency during the 60-day episode
  • Within 48-hours of return from a hospital admission of 24-hours or more for reasons other than diagnostic tests or on the physicians ordered resumption of care date
  • At discharge

CoP 484.60 Care Planning, coordination of services and quality of care reference the individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including the responsible disciplines and the measurable outcomes the agency anticipates will occur with the implementation of the interventions and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and the training provided specific to the needs of the patient.

Each patient must receive the home health services that are written in the individualized patient-specific plan of care that identifies the patient’s measurable outcomes and goals.

The plan of care must also include a description of patient’s risk for emergency department visits and hospital re-admission and all the necessary interventions to address the underlying risk factors. 

The patient and caregiver education to facilitate timely discharge must also be included.

Any information related to advance directives must be included on the plan of care.

There were no previous requirements removed from the plan of care.

The home health agency and clinicians providing care to patients must conform with the physician provided orders. Drugs, services and treatments are only administered as provided by the physician responsible for the patient’s care while receiving home health.  When services are provided on the basis of verbal orders, these must be documented in the patient’s clinical record, signed, dated and timed.  Verbal orders must be authenticated and dated by the physician in accordance with applicable state laws, as well as the agencies policies.

Review and revision of the plan of care must occur by the physician responsible for the patient’s care and the home health agency as frequently as the patient condition warrants, but no less frequently than every 60 days, beginning with the start of care date.  The agency is required to notify the physician promptly with any changes in the patient’s condition or any needs that may suggest that outcomes are not being met and/or the need for altering the plan of care.

Revisions to the plan of care must be communicated as follows:

  • Any revision to the plan of care due to a change in the patient’s health status must be communicated to the patient, the patient representative, if any, caregiver and the physician responsible for the patient’s care.
  • Any revisions to the plans for the patient’s discharge must be communicated to the patient, the patient representative, if any, caregiver and all physicians issuing orders for the home health plan of care, and the patient’s primary care practitioner and any other health care professionals who will be responsible for providing care after the patient’s discharge from the home health agency.

The coordination of the patient’s care is very important.  The home health agency must assure communication with all physicians involved in the plan of care. Orders from all physicians must be integrated into the plan of care to ensure coordination of all services and interventions provided to the patient. Agencies must also integrate all services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could impact patient safety and treatment effectiveness and the coordination of care provided by all disciplines. It is important to coordinate care delivery to meet the patient’s needs and to involve the patient, the patient representative and caregivers as appropriate. A key component of the coordination of care is to make sure patients, their patient representative and caregivers receive proper education and training provided by the agency regarding the care and services identified in the plan of care.

The home health agency must provide a written copy to the patient and the patient caregiver of the visit schedule, including the frequency of planned visits by the home health agency and by individuals acting on behalf of the agency. The agency must also provide the medication schedule including medication name, dosage and frequency and which medications will be administered by the agency if any. The written instructions must also include any treatments the patient will receive, including therapy services and any other pertinent information regarding the care they will be receiving as outlined in the patient specific plan of care.  

Lastly, the home health agency must provide to the patient, patient representative, if any and to the caregiver/s the name and contact information for the home health clinical manager.

Written by Peggy Patton, Vice President of Education Services

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