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CARE PLANNINGCHANGES YOU NEED TO MAKE TO SUCCEED IN PDGM
Care Planning Points to Ponder▪Who is generating your POC
▪What interventions and goals are you using? What order?
▪When is the POC created? How long does it take?
▪How do you know your interventions and goals are effective?
▪Why? Decrease days to RAP or PCR submission, improve outcomes, decrease your cost of care
WHO Creates your care plans?
PPS
▪ Field staff
Care plans very by nurse/ therapist
▪ Most EMRs imbed I/G inside each body system
Encourages “eval and treat” mentality
Produces “subjective assessment” CP
PDGM
▪ QA and outcomes trained staff
Standardize care plans
▪ Base primary care planning on the
REASON for the referral
Intervention on acute problem FIRST
▪ Focused I/G on;
Preventing re-admission
Fostering independence for PT/CG
Meeting outcomes
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Traditional Results
▪Limited outcomes
▪High re-admissions
▪Long LOS
▪Encouraging dependenceon HHA
WHAT Interventions and goals? Why?
Traditional PPS
▪Teach on every diagnosis
▪Teach on every medication
▪Have more I/G than can be met in one cert to provide reason to continue care
▪Agencies paid for 1w9 RC pattern
▪No penalty for hospital admission
▪I/G revolved around nurse managing patient
WHAT Interventions and goals? Why?
PDGM Results
▪Improving outcomes
▪Decrease cost of care
▪High STAR scores
▪Low hospital admissions
▪Aim for 30-50 days LOS
▪Encouraging independence and self care in chronic condition management
PDGM
▪Teach on Primary diagnosis and relevant unstable comorbidity
▪Reconcile/ review meds- then teach on new medications or meds related to primary dx
▪I/G concise and reachable and task oriented
▪Front load teaching for acuity
▪Penalty for hospital admissions
▪I/G revolve around patient/ CG independence
WHEN is the POC created?
▪Is your agency taking 12-14 days to complete your OASIS and create the POC?
▪30 day pay periods and decreasing margins mean HHA must become more efficient to survive
▪Delay in care planning also contributes to higher readmissions;
Nurses often just “pick” something to teach on in the absence of a care plan—example; falls, bathroom safety, etc.
Second visit is delayed waiting for plan
▪Same day care plan implementation
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HOW do you know POC is effective?PPS- locator 21
PPS POC?▪ Physicians
What are they signing?NPI linking concerns?
▪ CliniciansWhat are the priorities?Where do they start?
▪ QA teamHow do you document meeting all these goals?How do you measure these outcomes?Are interventions effective?
▪PatientsHow does this prevent hospitalizations?How does promote independence?
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Interpretive Guidelines §484.55(c)(2)
“Patient goal” is defined as a patient-specific objective, adapted to each patient based on the medical diagnosis, physician’s orders, comprehensive assessment, patient input, and the specific treatments provided by the agency.
Diagnosis based care planning is patient-specific
HOW do you know your I/G are effective?
Evidence based practice
▪Integrates the best available evidence to guide nursing care and improve patient outcomes
Diagnosis specific
▪Care planning must revolve around the patient’s primary reason for care
Systematic Process
▪Airlines, Surgery, MI
HOW do you know I/G are effective?
Home Health Quality Improvement– A CMS Initiative www.homehealthquality.org
Agency for Health Care Research and Quality–Department of Health and Human Services https://innovations.ahrq.gov
Delmarva Foundation - A subsidiary of “Quality Health Strategies,” Health Integrity (ZPIC) is another subsidiary http://www.delmarvafoundation.org
14 Quality Improvement Organizations(all states have one)
http://qioprogram.org/locate-your-qio
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Evidence Based Visit mapping Examplewww.tmf.org/Health-Care-Providers/Home-Health-
Agencies/Readmissions
https://www.homehealthquality.org/Special-Pages
COPD ExacerbationSN Frequency: 2w2,1w1
Physical Therapy 1w1 to evaluate and treat for gait deficit, weakness, and exercise for heart failure rehabilitation, as necessary.
Occupational Therapy 1w1 to evaluate for functional deficits in self-care as necessary
COPD Self-Care workbook
Tools for self-care and management
Define the diagnosis
Personal Goals and plan
Medicines
BORG scale
Diet and Nutrition
Energy Conservation
COPD
Zone
Tool
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Backbone for COPD- PDGM
Skilled Nurse 2w2,1w1 + Routine Phone call check-ins.
Physical Therapy 1w1 to evaluate and treat for gait deficit, weakness, and exercise for COPD rehabilitation, as necessary.
Occupational Therapy 1w1 to evaluate for functional deficits in self-care, as necessary.
VS parameters per agency
(Interventions for COP requirements; pain, foot assessment for DM, skin integrity as necessary)
SOC visit;
SN to review required teaching per COPs.
SN to define primary dx: Chronic Obstructive Pulmonary Disease.
SN to introduce zone tool for COPD management.
SN to review 30-day hospital readmission prevention plan.
SN to review and reconcile patient's medications.
SN to ask and document patient's goals for HH.
SN to review agency goal of disease self-management.
SN to teach patient importance of compliance with plan of care to reach goals.
SNV 2;
SN to teach COPD in terms easily understood.
SN to teach signs and symptoms of COPD exacerbation.
SN to teach COPD medications including inhalers
SN to teach COPD self-management strategies using zone tools.
SNV 3;
SN to assess patient’s behaviors and teach strategies to prevent symptoms from worsening.
SN to teach diet and nutrition guidelines for COPD management.
SNV 4;
SN to assess patient knowledge and application ability of the zone tool.
SN to introduce and teach the BORG scale.
SNV 5;
SN to assess and reinforce patient's COPD self-management understanding and guidelines.
SN discharge teaching to include; medications, diet, exercise, daily weights, use of zone tools and BORG scale, how/when to take action and keep
physician appointments.
Backbone for Pneumonia- PDGM
Skilled Nurse 2w2,1w1 + Routine Phone call check-ins.
Physical Therapy 1w1 to evaluate and treat for gait deficit, weakness as necessary.
Occupational Therapy 1w1 to evaluate for functional deficits in self-care as necessary.
Interventions for COP requirements; pain, foot assessment for DM, skin integrity as necessary.
SOC visit;
SN to review required teaching per COPs.
SN to define primary dx: Pneumonia.
SN to introduce zone tool for Pneumonia management.
SN to review 30-day hospital readmission prevention plan.
SN to review and reconcile patient's medications.
SN to ask and document patient's goals for HH.
SN to review agency goal of disease self-management.
SN to teach patient importance of compliance with plan of care to reach goals.
SNV 2;
SN to teach Pneumonia in terms easily understood.
SN to teach signs and symptoms of Pneumonia and warning signs of decline in condition.
SN to teach Pneumonia specific medications including inhaler use.
SN to teach Pneumonia self-management strategies; hydration, coughing and deep breathing, and zone tool.
SNV 3;
SN to assess patient’s behaviors and teach strategies to prevent symptoms from worsening.
SN to teach diet and nutrition guidelines for pneumonia management.
SNV 4;
SN to have patient demonstrate inhaler use.
SN to educate patient on pneumonia vaccine.
SN to assess patient knowledge and application ability of the zone tool.
SNV 5;
SN to assess and reinforce patient's Pneumonia self-management understanding and guidelines.
SN discharge teaching to include; medications, diet, graded activities, use of zone tool, how/when to take action and keep physician appointments.
Co-morbidities-When do they matter??▪Co-morbidities which combine to increase reimbursement under PDGM may or may not be appropriate for the patient’s care plan
▪The clinician’s comprehensive assessment of the patient’s health and functional status along with the patient’s knowledge of their medical condition must be considered
▪Goals must be individualized to the patient based on the patient’s medical diagnosis, physician’s orders, comprehensive assessment and patient input
▪Always assess the stability of a co-morbidity first
▪Provide I/G on co-morbidities only if;
They are unstable
They have a correlation to the primary diagnosis
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Patient A
is referred for home health after an exacerbation of CHF. He also has diabetes. The clinician determines at the comprehensive assessment, the diabetes is long standing and stable with a normal HA1C. The patient is also able to demonstrate how to check his blood sugar and follows his prescribed diet and medication regimen. The HHA lists CHF as the primary DX and diabetes is listed as a co-morbidity. The HHA does not include any interventions and goals for diabetes (other than those required by the COPs).
Patient B
is referred for home health after an exacerbation of CHF. He also has diabetes. The clinician determines at the comprehensive assessment, the diabetes is not well controlled, the patient is not able to demonstrate use of his glucometer and is not adhering to his diet. The HHA lists CHF as the primary DX and diabetes is listed as a co-morbidity. The HHA addresses the knowledge deficit for diabetes with interventions and goals in addition to those for CHF on the patient’s care plan.
Examples…..
Combined COPD/ PneumoniaSkilled Nurse 2w2,1w1.
Physical Therapy 1w1 to evaluate and treat for gait deficit, weakness as necessary.
Occupational Therapy 1w1 to evaluate for functional deficits in self-care as necessary.
Interventions for COP requirements; pain, foot assessment for DM, skin integrity, as necessary.SOC visit;
SN to review required teaching per COPs.
SN to define primary dx: Chronic Obstructive Pulmonary Disease/ Pneumonia
SN to introduce zone tool for COPD/ Pneumonia management.
SN to review 30-day hospital readmission prevention plan.
SN to review and reconcile patient's medications.
SN to ask and document patient's goals for HH.
SN to review agency goal of disease self-management.
SN to teach patient importance of compliance with plan of care to reach goals.
SNV 2; (within 24 hours/ 90-minute intensive visit)
SN to teach COPD and pneumonia in terms easily understood.
SN to teach s/s of COPD exacerbation and warning signs of decline in condition of pneumonia.
SN to teach COPD and pneumonia medications focusing on inhaler, nebulizer medications
SN to teach COPD/ pneumonia self-management strategies; zone tools, hydration, coughing and deep breathing
SNV 3;
SN to assess patient’s behaviors and teach strategies to prevent symptoms from worsening.
SN to teach diet and nutrition guidelines for COPD/ pneumonia management.
SNV 4;
SN to assess patient knowledge and application ability of the zone tool.
SN to introduce and teach the BORG scale.
SN to have patient demonstrate inhaler / nebulizer use.
SN to educate patient on pneumonia vaccine.
SNV 5;
SN to assess and reinforce patient's COPD/ pneumonia self-management understanding
and guidelines.
SN discharge teaching to include; medications, diet, exercise, graded activities, use of zone
tools and BORG scale, how/when to take action and keep physician appointments.
Combined COPD/ Pneumonia- con’t
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Where do I start care planning?
Top National DRG’s causing readmissions
CHF, COPD, Pneumonia, AMI,CABG, TKR/THR, Diabetes
Research the top DRG by cost in your county and offer your anchor hospital a solution https://data.cms.gov/mapping-medicare-disparities
Care planning and the regular skilled visit
MBPM 40.1.1 CMS Requires the Home Health Clinical Notes must document as appropriate:
1. The history and physical exam pertinent to the day's visit, …..and
2. The skilled services applied on the current visit, and
3. The patient/caregiver's immediate response to the skilled services provided, and
4. The plan for the next visit based on the rationale of prior results.
**Continue with POC and tolerated well are not acceptable
SNV 2;SN to teach COPD in terms easily understood.SN to teach signs and symptoms of COPD exacerbation.SN to teach COPD medications including inhalersSN to teach COPD self-management strategies with zone tools.Goals for SNV 2;Patient/CG will verbalize understanding of how COPD affects the lung function.Patient/CG will be able to list signs and symptoms of COPD exacerbation.Patients/ CG will verbalize understanding of COPD medications; actions and SE.Patients/ CG will verbalize use of weight log and zone tools daily.SNV 3;SN to assess patient’s behaviors and teach strategies to prevent symptoms from worsening.SN to teach diet and nutrition guidelines for COPD management.
Care planning and the regular skilled visit
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Guidance SNV Charting Example
The history and physical exam pertinent to the
day's visit, (including the response or changes
in behavior to previously administered skilled
services)
Head to toe assessment is performed and documented in visit note-
Patient is accurately teaching back to the SN the re-hospitalization plan and the use of the zone tool, has
been compliant with all medications from last visit, and is compliant with medications.
(taught on visit 1)
and the skilled services applied on the current
visit, and
Educated the patient on the disease process of COPD, and Chronic Bronchitis.
Educated patient using the zone tool and on ss of exacerbation including, SOB, weakness, increased
cough and sputum.
Educated the patient on the proper sequence of breathing and inhaling while dispensing the dose, holding
the medication in the lungs, and then exhaling.
the patient/caregiver’s response to the skilled
services provided, and
The patient and his wife have verbalized understanding of COPD diagnosis, how it affects lung function,
and pre-exacerbation s/s to look for and report/self-manage the disease process before it gets out of
control.
SN watched the patient using his inhaler, confirming proper breathing and inhaling with the coordination of
dispensing the dose.
the plan for the next visit based on the rationale
of prior results, a detailed rationale that explains
the need for the skilled service in light of the
patient’s overall medical condition and
experiences,
the complexity of the service to be performed..
Next visit SN to assess for patient compliance to teaching at visit 2 and reinforce teaching as needed. SN
to teach patient strategies to prevent exacerbation of COPD and lung symptoms and diet considerations
for COPD
But What About Maintenance Care?
Jimmo VS Sebelius
“The Centers for Medicare & Medicaid Services (CMS) reminds the Medicare community of the JimmoSettlement Agreement (January 2013), which clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).
Skilled nursing services would be covered where such skilled nursing services are necessary to maintain the patient's current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided.
Skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program.
Https://www.cms.gov/Center/Special-Topic/Jimmo-Center
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Does the patient require skilled care, therapy, to prevent or slow the deterioration of the patient's medical/functional status.
Has the patient reached MMI "Maximum Medical Improvement."
No-Stop
Can the service be provided at a lower level of care, i.e. the patient performs the program independently or with the
assistance of a family member or caregiver? (Not having a family member or caregiver to
perform the program with the patient is NOT a reason to substantiate a skilled service)
May provide maintenance Care
No-Stop
Yes-Stop
Maintenance
Care
Decision
Tree
What Must be Documented for Maintenance Care to Pass Audit?
1. Document why the program requires the skill of a clinician to provide the service.
2. Document the patient’s condition, the state of stability that’s been achieved, and exactly what you intend to preserve, or maintain, etc.
3. Document what decline in patient status would indicate the re-engagement of restorative services.
4. Re-Examine and carefully document homebound status-What stops the patient from getting equivalent services outside of the home?
On a Maintenance Care Plan
Interventions
would all pertain to the specific function the patient needs to preserve or maintain (the reason for home health!)
Goals
The maintenance of “________function” as evidenced by __________
or to prevent or slow further deterioration of _______________
There may be only one goal for this type of care planning
DO NOT list goals that would require improvement in patient function as that would undermine the credibility of your maintenance care plan
Frequency must be “reasonable and necessary” = lower than restorative care
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Care Planning COVID-19 and Telemedicine
How to Get Started
QA Department
▪ Must be in the Plan of Care or other order required
▪ Must not replace an ordered in person visit
Buy your own and make a kit
▪ Buy scale, automatic BP cuff, 02 monitor, thermometer, etc. from medical supply company
and either disinfect after use or donate to patient.
▪ Use tablet or phone for video interaction
Partner with telehealth company
▪ Often manage inventory and provide infection control
▪ Usually contain scale, BP cuff, 02 sat monitor, screen with interactive teaching modules
and assessment tools may allow for video conferencing (optional diabetic equipment)
Telephone visit #1. Post admission:
OASIS assessment and Care planning is completed within 4-hours of visit.
Care Plan includes telephonic teaching protocols.
Telephonic team establishes contact the next day
ON THE CARE PLAN:
◦ Telephone Nurse Recap’s reason for admission & Patient’s health Goals
◦ Patient to teach back to caller re-hospitalization protocols
◦ Evaluate patients needs vs resources
◦ Evaluate Patient/s ability & willingness to participate in the established POC
◦ Review new medications & orders/protocol
◦ Review what is to be achieved by patient before the next visit
◦ Preview what is to be taught/covered/expected during the next visit
Care Planning the Telephone Visit
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TELEPHONE VISIT #2
- SN to review/ teach CHF in terms easily understood.
- SN to review/ teach signs and symptoms of CHF exacerbation.
- SN to review/ teach CHF medications.
- SN to review/ teach CHF self-management strategies; daily weights and zone tools.
Patient to teach back.
GOALS FOR VISIT:
- Patient/CG will verbalize understanding of how CHF affects the hearts function.
- Patient/CG will be able to list signs and symptoms of CHF exacerbation.
- Patients/ CG will verbalize understanding of medications; actions and SE.
- Patients/ CG will begin to keep daily weight logs and verbalize meaning of zones.
Between Face to Face visits
Care Planning the Telephone Visit
TELEPHONE VISIT # 3
Recap all items from Visit #1
AND
◦ SN to assess and teach patient use of weight log using teach back technique.
◦ SN to teach diet and nutrition guidelines for CHF management.
Goals for SNV 2
◦ Patient will be proficient with teaching and goals from Visit #1
AND
◦ Patient/ CG will teach back use of weight logs and when to call SN or MD.
◦ Patient/ CG will verbalize understanding of diet requirements in CHF management.
Care Planning the Telephone Visit
TELEPHONE VISIT # 4 Pre-Discharge
Recap all items from Visit #1 & 2
◦ AND
◦ SN to assess and reinforce patient's CHF self-management understanding and guidelines.
◦ SN discharge teaching to include; medications, diet, exercise, daily weights, use of zone tools, how/when to take action and keep physician appointments.
Goals for telephone visit #3
◦ Patient will be proficient with teaching and goals from Visit #1&2
◦ AND
◦ Be able to; self-manage CHF to prevent exacerbation to include daily weights, zone tool.
Maintain compliance and understanding of medications be compliant with CHF diet and
exercise plan. Patient will keep all follow up appointments with physician.
Care Planning the Telephone Visit
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Week 1 1 2
SOC
1
3
TH
2
4
PT Eval
3
5
TH
4
6
SN
5
7
6
Week 2 8
TH
7
9
8
10
PTA
9
11
10
12
11
13
TH
12
14
Week 3 15
TH
16 17
SN
18 19 20
TH
21
Week 4 22 23 24 25 26 27
TH
28
Week 5 29 30
PT
31 32 33 34
TH
35
Week 6 36 37 38 39 40 41
TH
42
Week 7 43 44 45
PTA
46 47 48 49
Week 8 50 51 52 53 54 55
TH
56
Week 9 57 58 59
SN
60
E1 P1
SN 3
PT 3
6 visits
E1P2
SN 1
PT 1
2 visits
Tele-Phone
10 visits
Total
18 visits
Logistics & Scheduling
Days to RAP
GR
EEN
ZO
NE
ALL CLEAR (GOAL)
• Cough with no wheezing, or shortness of breath
• Low grade fever relieved with fever reducing medication
• Appetite is good
Doing Ok-Your symptoms are under
control
• Actions: o Stay home in a “sick room” away
from other people and pets o Use a separate bathroom o Postponing doctor’s appointments
or use telemedicine o Wear a covering over mouth and
nose if you must be around anyone o Sneeze or cough into a tissue and
throw into a lined trash can o Wash hands with soap and water
for at least 20 second frequently o Avoid touching your eyes, nose, or
mouth with unwashed hands
YEL
LOW
ZO
NE
CAUTION (WARNING)
If you have any of the following:
• Sputum (phlegm) increases, color changes, or it thickens
• More trouble breathing or more coughing with activity
• Extra pillows to sleep
• Medicine is not helping
• Appetite not very good
Act Today!
• Means you need further evaluation
• Actions: o Call your home health nurse
(agency’s phone number)
o Or call your doctor
(doctor’s phone number)
RED
ZO
NE
EMERGENCY
• Trouble breathing or wheezing at rest o Hard to walk or talk
• Chest pain or tightness that does not go away
• New confusion or inability to arouse
• Lips or fingernails turn blue or grey
Act NOW!
• Means you need to be seen by a doctor right away. Call ahead and tell the facility or ER if you have tested positive for COVID-19
• Actions: o Go the Emergency Room
o Or call 911
https://www.cdc.gov/coronavir
us/2019-ncov/if-you-are-
sick/steps-when-
sick.html#warning-signs
COVID-19 ZONE
TOOL- Diagnosed
or Suspected
Questions and Contact Information
Michael McGowan
President, CEO
OperaCare, LLC
Kristi Bajer BSN, RN, COS-C
Vice President, Clinical Operations
OperaCare, LLC
Office: 888.886.7372 ext 709
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