The new Conditions of Participation (CoPs) incorporate a focus on patient-centered care. A growing concept within the health care industry over the past several year, patient-centered is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.”  Effective episode management is critical to all home health agency’s success in incorporating patient-centered care strategies to increase compliance with these new conditions. 
Patient-Centered Goals

Effective episode management incorporates a focus on goals of care. This focus on establishing goals ensures enhanced participation and buy-in to the home health plan of care from patients and caregivers. With enhanced buy-in, chances of success with the home health plan of care are significantly increased.  Some things to consider:

  • Is your staff aware of the new focus on patient-centered care and the expectation for documentation of patient-centered goals?
  • Does your agency’s electronic medical record (EMR) have a prompt for documentation of patient-centered goals?
  • Are your staff aware of where they are expected to document the patient-stated goals?

Through episode management review, your administration can identify the need for staff education on patient goals and provide the training in a timely manner to improve successful outcomes. Managers may easily identify whether patient-stated goals are being documented, as well as whether the clinicians are aiding their patients to refine the goals to ensure they are measurable and realistic.

Missed Visits & Refusals of Care

Another important focus of the new CoPs is missed visits and refusals of care.  The draft interpretive guidelines heavily focus on agency expectations for handling these areas.  Episode management success includes initiation of industry best practice standards.  A focus on best practices regarding missed visits and refusals of care should be a priority to ensure success with the plan of care, as well as compliance with CoPs expectations.

Comprehensive Assessment

The comprehensive assessment is another area of focus in the new CoPs. Clinicians may have difficulty understanding how to comply with some of the new provisions, especially related to the new guidelines regarding patient’s strengths, goals, care preferences and identification of the primary caregiver’s willingness, availability, and schedule.  Your agency should ensure that staff are aware of these new changes and are educated in where to document this information within the EMR. Through ongoing clinical review management, staff can identify any potential areas of omission, inconsistency, as well as any areas requiring additional follow up.  These areas of concern should be identified early, and corrective action initiated timely to prevent adverse outcomes.

Clinician Education

To ensure success, it is important to have the right strategies/plans in place.  Teach clinicians to identify patient goals and include them on the plan of care.  Educate clinicians to utilize integrated chronic care management strategies to promote patient self-management, such as motivational interviewing, open-ended questions, active listening, reflection and summarization as well as teach-back and the development of SMART goals.  Develop an appropriate plan of care utilizing best practices such as front-loading, and rescheduling missed visits to adhere to the plan of care. Educate clinical staff in best practice strategies and provide ongoing reinforcement of this to allow for continued growth.

Risk Assessments

To improve agency success with CoP compliance and continued delivery of effective, efficient and patient-centered care, develop strategies to support effective episode management that direct the plan of care. Here are a few risk assessments you can be utilizing to direct the plan of care:

  • Fall risk
  • Skin breakdown risk
  • Pain assessment
  • Depression screening
  • Hospitalization risk

In fact, the new CoPs have added the expectation that risk for emergency department and hospital readmission be included on the plan of care along with necessary interventions to address the risk factors. Risk assessments should be completed with each new episode of care, including at SOC, ROC, and recertification.  When an intervention is made to address risk, it should be documented in the plan of care.

Care Coordination & Clinical Manager Role

Expectations regarding coordination of care have been expanded in the new CoPs.  Additionally, the Clinical Manager role has also been broadened.  CMS expects agency’s Clinical Managers to oversee scheduling, coordinating patient care and referrals, as well as assuring that patient’s needs are continually assessed and that the plan of care is appropriately developed, implemented and updated.  Effective episode management should include the development of strategies to support coordination of care and ensure compliance with the Clinical Manager standard.

Coordination of care should start even before the SOC. Home health agency liaisons and/or intake clinicians may complete a home health pre-screening tool to identify appropriateness for home health and potential service needs prior to the SOC.  A high-risk screening tool may be used at the time of intake to proactively identify potential high-risk episodes and initiate high-risk protocols prior to the SOC. After SOC/ROC or recertification, a SOC/ROC or recertification hand-off should occur between the OASIS clinician, the case manager as well as the overseeing clinical managers.  Routine interdisciplinary case conferences, team meetings and weekly one-on-one case conferences should be held with focus on patient goals, barriers to care and any modifications to the plan of care to improve the chances of success.  Clinical review should include assessment of compliance with transfer and discharge summaries as well as communication with physicians as required by the new CoPs.

Ensuring that you have an effective episode management program in place improves your chances of CoPs compliance by providing the necessary management, patient-centered care, and oversight expected by CMS. 

About The Contributor

Carissa McKenna, Clinical Consulting Manager

Carissa expertise includes assisting agencies in attaining clinical and financial goals as well as improving patient satisfaction through continuous, proactive episode review processes. Agencies are thereby able to demonstrate pursuit of CMS’ Triple Aim: To improve patient experience of care, improve patient health, and decrease the per capita cost of health care delivery.