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5 Tips for Compliant and Patient-Centered Plan of Care

    The Plan of Care (POC) is a vital component of home health care as it promotes patient-centered services and facilitates effective collaboration among care teams working with the patient. It is also a requirement for Medicare claims reimbursement, and strict adherence to highly specific documentation guidelines is crucial. Issues related to POC compliance often result in claims denials; therefore, home health agencies must diligently maintain compliant POC documentation.

    Tips for Compliant and Patient-Centered POC

    1. Present a clear patient profile
      • Personalize the care plan to align with the client’s unique needs, preferences, and cultural background. Use assessment data that encompasses both medical and psychosocial dimensions of care.
      • According to the Conditions of Participation (COP), a personalized POC should cover a patient’s mental, psychosocial, and cognitive status, as well as their functional limitations and rehabilitation potential. Remember that the vital signs parameters vary based on the patient’s current health condition. Clinicians must gather these details during the comprehensive assessment as they all come together to shape a care plan specifically for the patient.
    2. Establish homebound status and medical necessity
      • Clinical findings should affirm the patient’s eligibility for home health services. The POC should provide evidence that the patient fulfills both the homebound criteria 1 & 2.
      • Document the patient’s functional and structural limitations to support the reason for home health admission.
      • Assess functional impairments like weakness, difficulty in ambulation, limited mobility/ROM, joint discomfort, and balance issues to substantiate the medical necessity for specific services.
      • Make sure that the set visit frequency is medically necessary based on the patient’s case.
    3. Establish patient-specific treatment goals and corresponding interventions
      • Collaborate with the patient and their family or caregiver to establish realistic and achievable goals. Goals set should adhere to the SMART principle: specific, measurable, attainable, relevant, and time-bound.
      • Make sure that goals and interventions address the focus of care as reflected in the comprehensive assessment and home health referral orders
      • Take into account the patient and caregiver education during care planning to ensure an effective continuity of care. Effective care delivery is a team effort involving both the patient and their caregiver, who play a significant role in implementing the treatment plan.
      • Make use of available resources recommended by Medicare. If close monitoring or consultations are necessary, consider utilizing telehealth technology, especially for clients with mobility challenges.
    4. Demonstrate the intent to improve the patient’s health status.
      • Regularly evaluate and document the patient’s progress toward set goals.
      • Perform discharge planning as it is an integral part of every POC. Anticipate patient’s health care needs and ensure appropriate patient and caregivers education is provided.
      • Take note of required durable medical equipment (DME) and supplies, which help in demonstrating the intent to improve the patient’s health status.
    5. Follow physician’s orders and address the focus of care
      • When formulating the POC, ensure its clear inclusion of the initial physician’s order, addressing the focus of care or the reason for home health admission. 
      • Remember that one of the leading causes for payment denial is the absence of a valid face-to-face encounter supporting the primary diagnosis or its non-mention in the face-to-face encounter altogether. 
      • Comorbidities listed must be supported with adequate documentation. Whether found in prior medical records or within the OASIS, such documentation provides the essential foundation for creating tailored treatment plans that cater to the patient’s unique needs.

    Ensuring Accuracy in POC Documentation

    The home health Plan of Care incorporates information from various home health documents, including the OASIS and face-to-face encounter documentation. Therefore, it is crucial that the plan of care aligns with them, serving both efficient care administration and compliance purposes.

    Creating the plan of care involves considering many aspects, making it challenging to ensure accuracy and consistency across other related documentation. Your QA program plays a significant role in ensuring that your plan of care adheres to compliance guidelines. Specifically, your QA program should cover these common areas of oversight in the POC.

    • Compliance with the COPs
    • Consistency of information with the comprehensive assessment and F2F encounter note
    • Relevance of goals and interventions address the focus of care as reflected in the comprehensive assessment
    • Medical necessity of visit frequencies

    The effectiveness of a home health care plan depends on careful attention to detail, clear communication, and collaborative efforts among stakeholders. By implementing the aforementioned tips and best practices, home health providers can develop care plans that not only enhance patients’ well-being but also ensure compliance with established guidelines.