Written by Carissa McKenna, Director, Clinical Consulting, McBee

In the Home Health environment, we have seen many changes over the past several years.  These changes have continued to create varying levels of understanding regarding what home health care is about. This confusion extends to all participants involved in care: physicians, patients, providers and clinical staff as well.

Therefore, it is vital that the Start of Care (SOC) clinician helps the patient/caregiver understand the importance of home health, how home health works and how their home health benefit helps support their care.

Both the patient and the home health care staff must work together to achieve the best clinical outcomes for the patient.

Tips for the home health SOC clinician:

  • Sit down, relax and make eye contact with the patient, introduce yourself and explain why you are there to see them.
  • Ask the patient what is most important to them regarding the care they are about to receive. “What Matters Most” to them? OR What were they able to do before that they are not able to do now?
  • Avoid medical jargon or acronyms, such as CHF, MI, and COPD and frequently check in with the patient to ensure understanding of the information provided and address any questions in order to prevent misunderstandings before they occur.

Scripting can help! Scripting is not meant to be read to the patient, but rather used as a guide to help staff with alternative phrasing when communicating important points to the patient/caregiver to facilitate better understanding and enhanced recognition of the benefits home health services can provide them.

Scripting is relevant for all SOC visits no matter which discipline is involved.

Below are some examples of scripting that can be utilized at SOC to emphasize the importance and impact of home health services.

Start of Care Assessment

“Your doctor has ordered home care services to help you get back to the way you were before (list the patient’s illness/exacerbation/reason for recent hospitalization, etc.). Please stop me at any time to ask questions.

Your doctor ordered home care (list the services ordered – SN, PT, OT, ST, MSW, HHA) because you have (specify the issue/reason the doctor referred the patient). The first step in the process is what I am here to do today. I will perform a full assessment/evaluation of you to determine how we may best help you at home and make sure that you meet Medicare’s specifications for coverage of home health services. This assessment will also help me determine whether you require additional care beyond what your doctor originally requested. If you qualify for services that your doctor did not order, we can call your doctor to get an order to ensure you receive the services that you need.”

Participation between patient/caregiver and home health clinician

“In home health we work in partnership with you, working together to help you reach your goals. Let’s first talk about what matters most to you. This helps us focus on what is most important to you when setting up your plan of care.  Tell me, what matters most to you? OR What is something that has a lot of meaning to you, but you’ve not been able to do lately due to your (specify illness/injury/condition)?

It sounds like (repeat what it is the patient told you matters most to them) is really important to you! How do you think we could best help you work toward achieving that?

You are the most valued member of our care team. Letting us know what is important to you and helping us figure out how we can best help you allows us to truly makes strides toward achieving your goals. What I heard you say is that we can best help you by (repeat what the patient said you could help them with).  Would it be OK for me to share with you some recommendations I have based on that? Share your recommendations for the plan of care and connect them to how they will help the patient move toward achieving their goal.

Keep in mind that, at times, we may ask you to do some things when we are not here but rest assured that those things will help you continue to work toward achieving (repeat what matters most to the patient).”

Plan of Care

“After I complete your evaluation, we can discuss areas where it appears we may be able to help you get better and meet your goals. Medicare expects us to provide these services to you to help you get better faster. I will explain to you the benefit of each of the services that are recommended and what they will contribute to your plan in order to meet your goals.”

Important Tips for “Getting it Right at SOC”

  1. Engage the patient/caregiver right from the start by identifying “What Matters Most”
  2. Ensure the patient/caregiver understand the Medicare home health benefit
  3. Evaluate what the doctor ordered, identify any additional needs, and follow up with the doctor timely to obtain orders for additional services
  4. Work together to help achieve patient goals – Teamwork is the key to success!
  5. Encourage patient/caregiver adherence to the Plan of Care to yield the most successful outcomes.

In summary, “getting it right at the SOC” is a multi-factorial process and requires participation and involvement of the admitting clinician, patient, caregiver, ordering provider and all members of the care team. Scripting is a helpful tool to enhance communication between clinicians and patients/caregivers as well as improve patient/caregiver understanding of the Medicare home health benefit. Identifying “What Matters Most” helps to engage the patient in their care. Patients who are engaged in their care typically have better buy in to the home health plan of care leading to improved patient satisfaction and more optimal outcomes.

About the Author

Carissa McKenna, BSN, RN, HCS-D, COS-C, Director, Clinical Consulting

Carissa McKenna, BSN, RN, HCS-D, COS-C, Director of Clinical Consulting at McBee, has more than 25 years of experience in the health care industry. In her role at McBee, she has been involved in many aspects of client fulfillment, including OASIS and coding, episode management and on-site education. While specializing in performance improvement, Carissa is also experienced in managed care, health maintenance organizations, quality assurance, clinical documentation, integrated chronic care management, and education. She is experienced in both the home health and hospice survey processes, accreditation compliance, and Medicare regulations. While working with providers, Carissa has developed and implemented several clinical workflows, as well as documentation and quality assurance tools.

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