This chapter sets the stage for why home care is so different from other practices and business settings. Because the patients and families served are "out there" in the community, this different foundational construct has implications for care delivery, operations, and management, and sometimes home care team members feel "alone" because of this. In fact, this feeling, when reported, can be addressed and supported. This chapter provides a snapshot of some quantifiable data that helps make clinicians and managers know they're part of a large and growing community.

This chapter provides a practical and working definition of holistic home care and health care services provided at home. In this chapter we address the varying models and structures of the kinds of home care programs that provide unique and specialized services.

Generally, we only go into people's homes or get invited in when we know them. The person who lives in the home and their family members are truly the "unit of care" in home care. This chapter addresses some of these differences and nuances that impact practice and operations. From a practical perspective, this means that we function on somebody else's turf and home place. Though we may have been a clinician or manager where we had operational responsibility for a large group of patients in a hospital or nursing home or other facility, it is learned that in home care, this power shifts to the patient.

This summary chapter begins by describing a home visit or a shift in home care by showing an example of a patient, an older woman with chronic conditions that demand skilled care and visits. This chapter delves into the kinds of specialties that are seen in home care, another quality and safety factor when skill-matching patients and clinicians. The topic of how to make a home visit, which, of course, has implications for any type of home care, is presented in its own 60-minute CE course offering. Similarly, there is another course offering entitled Team Member Safety in the Community and Patient Home.

This chapter sets the stage for why home care and its documentation and related requirements are different from those of other settings. The external framework is Medicare and the Medicare Conditions of Participation (CoPs) related to documentation standards, compliance with state regulations, agency policy, accreditation, and other relevant regulatory and practice manuals. Other external drivers that impact care and documentation are also addressed.

This chapter will address the purpose and roles of documentation. The documentation should "tell the patient's story," support communication and care coordination, and facilitate the care planning process. Care coordination will also be defined from a practical perspective related to care, the individualization of care, and the documentation implications.

This chapter will explain oversight as it relates to home care and home care documentation. Who is accessing your documentation, and why? There are multiple organizations reviewing your records, some of which will be discussed in this chapter. Home care integrity, knowledge of and adherence to the rules, and the interface of regulation, payment, and quality in home care and home care documentation will also be discussed.

This chapter begins with a patient example to highlight the detailed documentation needed to support coverage and other tenets of home care. Through this example, we will demonstrate the documentation standards required for a comprehensive assessment and why this is important. We will also delve into the definition of "homebound" and other criteria that must be met for appropriate admission. We will explore the required elements of a comprehensive assessment, including how to assess for the medical, nursing, social rehabilitative, and discharge planning of the patient, and the need for physician orders will be addressed from a practical and regulatory perspective.

In this chapter, our patient example continues as we review supporting medical necessity in communication and care coordination for our sample patient. The care planning process continues, looking at using our critical thinking skills of reasoning, analyzing, evaluating, problem-solving, and decision-making to create the best individualized plan of care. The planning process continues with the collection of information, reflection, formulating the plan, and implementing the plan. In this chapter, it is emphasized that the patient's holistic assessment drives the care. In this example, you'll see that problems derived from the assessment deserve thoughtful consideration and care planning with a clear explanation as to why the patient does or does not need care for this the identified problem or deficit.

This chapter reviews the foundational tenets of effective documentation, with an emphasis on best practices and standards, to meet numerous regulatory requirements that are evidenced in documentation.

Developing an effective care plan is an essential element in the provision of services to the home care patient. Incorporating an interdisciplinary, holistic approach fosters successful patient outcomes. This chapter will define what is meant by the term "care plan," discuss the impact of the patient and family inclusion in this process, and examine the important function this process plays in care delivery. An introduction to the steps of the care planning process will be provided.

The comprehensive assessment begins the care planning process. The clinician's knowledge and use of specialized assessment skills in collecting data plays an integral role in the success of the care planning process. This chapter will identify the elements of a holistic comprehensive assessment per the Medicare Conditions of Participation and discuss the skill set required to effectively perform the assessment.

The accuracy of problem identification and prioritization impacts the effectiveness of the plan of care and your patient's achievement of care outcomes. Actual and potential problems relevant to the home health episode are identified based on the comprehensive assessment. This chapter will discuss how to identify relevant patient problems and prioritize them to support successful goal attainment.

The planning process includes two elements: the development of patient-centered goals/outcomes and the identification of interventions to support successful goal attainment. This chapter will discuss the structure of how home care goals/outcomes are written and the very important role of patient and caregiver involvement in actual goal development. The process for determining appropriate interventions to support goal attainment will be discussed from a regulatory and reimbursement perspective. The responsibility of the home care clinician to communicate the plan of care to the patient/caregiver will also be discussed.

Effective interdisciplinary care requires communication, collaboration, and coordination. These elements are essential in the care delivery process. This chapter will discuss these key concepts and provide strategies for efficient and effective care delivery.

The flexibility of the care planning process allows for evaluation of the effectiveness at any point in the process. This chapter will examine what aspects are evaluated, the process to perform an evaluation, and what to do when the plan is not working.

A knowledge of the community is key to safety-related initiatives in providing home care visits to people in varying neighborhoods and areas. Sadly, we only have to watch the news to hear that there is another random shooter or other dangerous and scary event. This chapter seeks to help answer the question: what if? The Centers for Medicare and Medicaid Services (CMS) established national emergency preparedness requirements for all organizations, such as home care and hospice, participating in the Medicare and Medicaid programs. In the State Operations Manual (section 484.22) are the related Conditions of Participation for Home Health Agencies (HHAs). These became effective in November, 2017. The bottom line is that we have an important role to play and that we must be prepared, whether the emergency be caused by nature, such as ice storms, tornadoes, or hurricanes, or other situations, such as an active shooter situation.

There is a method of assessing a neighborhood or community through an effective and detailed Windshield Assessment. This seemingly simple process can identify much information about a given neighborhood or area. This windshield assessment is accomplished to identify possible safety hazards and risks for both the clinicians and their patient populations.

The fundamentals for home visit safety begin on the road. This includes a car in good working condition, a method for getting roadside assistance, having a full tank of gas, not leaving your purse on the passenger seat where it can be seen, and not leaving patient records where patient information might be seen (HIPAA). This also includes looking around your car for safety concerns on getting in and out of the car. These and other common safety concerns will be addressed in this chapter.

There are a number of common and known hazards in homes. The home care clinician must have an awareness of their surroundings at all times in the community and in the patient's home. Hazards found in the home can include dangerous pets, smoking, poor structural maintenance, infestations, unclean homes, blood-borne pathogens, unsafe water, tripping hazards, and many more. Others include risks to personal safety from violence, stalking, and abuse.

Sadly, there have been instances of home care clinicians walking into situations that resulted in death and injury. These are related to the practice environment. This chapter seeks to educate and help minimize such situations, when possible.

This chapter sets the stage for the most common care delivery mechanism in home care: the home visit. A holistic definition of an effective home visit will be offered as well as practical application, where the patients are "out there" and the environment of care may be as varied as the patients served and homes visited.

In this chapter, pre-visit activities will be featured. With this topic come the detailed organizational and other activities that must be addressed to have a successful planned patient home visit. This information applies to many kinds of home visits, including skilled Medicare visits, well-baby visits, infusion care, hospice home visits, and other kinds of home visitation programs and models. Pre-visit activities will include obtaining physician orders and other demographic and referral information, identifying needed paperwork, completing any pre-admission work on your tablet or device, and more. A patient example begins here and follows through the home visit and post-visit activities. It is important to note that physician orders and coordination and communication activities are a key part of all of the visit's components.

Home care and home care visiting occurs in the context of local communities. Familiarity with your community and its strengths, areas for improvement, and resources can help make home visits more successful and safe. A brief desciption of a "windshield assessment" will be given as well as a brief overview of safety when out in the community and in homes. There are safety implications for both the patient and the home care team in the home and community. Some of these risks and factors will be addressed.

This chapter addresses the home visit and activities that occur once the team member arrives at the patient's home. Of course, there must be physician orders to see/assess/evaluate this patient. The initial visit may be the most important visit for a number of reasons. The visiting team member, such as a nurse or a therapist, has "new eyes" and can use this objective presence (only once!) to observe and use all senses to value incoming input and data. This is also the first time we meet our patient and is the initial assessment visit from which we start to create the actionable plan of care. During this visit, we clarify expectations and schedules and explain home care and home care services. We also begin the interactions that form the basis for the patient experience. This chapter addresses the processes to create a workable plan of care. This includes reviewing all the noted data from all sources, such as interviewing, observing, and the use of all of our senses for more data collection. We obtain/explain/complete the initial paperwork, including consent, and the mutually agreed-upon goals are developed with the patient and family/caregivers.

This chapter addressed the activities that take place after the visit has concluded. Sometimes we contact other team members, such as the physician (to collaborate/confirm the plan of care or to clarify any orders) or an aide supervisor or therapist, all to coordinate care and communicate information while at the patient's home. At this stage, it is important to clearly identify the patient's skilled care needs and validate that this patient and their care needs meet your organization's admission criteria.

This chapter provides a review of some of the most important parts of home care documentation after a patient visit: the comprehensive assessment, the plan of care, and the documentation of the care and services provided at this visit.

Understanding who is eligible and what services are considered covered under the home health Medicare benefit is an important aspect for reimbursement in a home care agency. If care is provided to an ineligible patient or non-covered services are provided, your agency cannot bill for those services. This chapter will introduce the Medicare Benefits Policy Manual, Chapter 7- Home Health with a brief review of contents.

It is important to remember that Medicare is a medical insurance program. On every visit made to a Medicare beneficiary, the home care clinician must determine if the patient meets or continues to meet the eligibility requirements of the Medicare home health program. This includes determining if the patient requires reasonable and medically necessary services and is confined to the home (is homebound); determining if the services are provided under a plan of care established and approved by a physician; assuring the patient is under the care of a physician; determining if the patient requires intermittent skilled nursing care, physical therapy, or speech therapy, or if the patient has a continuing need for occupational therapy, as well as physician certification/recertification. This chapter will examine each of these requirements, utilizing the guidance from the Medicare Benefits Policy Manual and examples to illustrate the intent of each of these requirements and the required elements to document effectively.

It is essential that every home care nurse and manager who cares for and/or supervises Medicare beneficiaries understand the services and coverage that Medicare reimburses, assuming all criteria are met and documentation supports covered care. As with all insurance products, there are covered and non-covered services. This chapter will discuss the 15 specific nursing services/skills with examples that are/may be covered, and the documentation required to support a reimbursable service. This information is housed in Chapter 7 of the Medicare Policy Manual, and this information should be the basis for care related to quality and coverage. Some of the fundamental tenets of what makes a service skilled will also be reviewed. It is important to note that just because it is a "coverable" service does not mean it will be covered. Clinicians in home care have an important responsibility to support covered care and services, and this is reflected in the clinical documentation.

This chapter will discuss the specific covered services/skills with examples that are/may be covered for each therapy discipline and the documentation required to support a reimbursable service.

This chapter will discuss the specific covered services/skills with examples that are/may be covered for home health aide services and the documentation required to support a reimbursable service.

This chapter will discuss the specific covered services/skills with examples that are/may be covered for Medical Social Services and the documentation required to support a reimbursable service.

This Chapter will show a quick and easy checklist tool to ask questions to help clinicians and managers determine quality and medical necessity by reviewing components of the clinical record. The use of peer review of clinical records to improve the quality, detail, and individualization of the patient clinical records is discussed.

This chapter looks at the definition of chronic condition management and how chronic conditions have changed in the last few decades. We will look at examples of chronic conditions as well as statistics about chronic conditions in the United States. This chapter also reviews patient, clinician, and system barriers. With this knowledge, the health care provider can continually assess for actual or potential obstacles to success.

This chapter discusses the evolution of chronic condition care and reviews chronic condition management models and best practices. Strategies to improve care of patients with multiple chronic conditions will be discussed. A patient case scenario will be introduced for review and consideration.

Patient self-management is the primary goal of the support system of caregivers and the health care team. Communication with vulnerable patients and addressing special population needs will be reviewed. Customized and personalized care that is patient centered will de discussed. The patient case scenario introduced in the prior chapter will be developed as an exemplar.

After the clinician has assessed the patient and the support system, a holistic plan needs to be developed. This chapter provides practical tools for the clinician to use to partner with the patient in his/her efforts to manage chronic conditions. This chapter will integrate information from prior chapters for clinicians to be able to apply the concepts presented to their practices and at their organizations.

This chapter provides an introduction to critical thinking as well as an overview of current thought and research on the topic. A practical definition adapted to home care will be presented. The creation of a personal definition of critical thinking and how it applies to practice in home care will be discussed. A correlation with the use of critical thinking and enhanced care delivery and patient safety will also be made.

This chapter incorporates case scenarios with an interview of a home care nurse to demonstrate the application of critical thinking in planning a home care provider’s day, plan of care development, care delivery and patient and family education. One may become more effective in daily practice by utilizing the strategies discussed in this section.

Clear communication is critical to safety and quality in home care. Whether that communication is between patients or families and clinicians, within the home care team or with primary care providers, clinicians can improve their communication skills with the use of critical thinking. Scenarios in this chapter will provide experiences with critical thinking in communication skills.

This chapter includes a discussion of the behaviors of critical thinkers and how those behaviors contribute to the planning and delivery of quality home care while promoting patient safety. These behaviors can have career implications as well as they align with state and professional scopes of practice. Developing a plan for the continuous inclusion of critical thinking in personal practice will also be discussed in this chapter.

Medicare is a medical insurance program and as such, the physician is responsible for the oversight of the care. Just as in a hospital setting, home care must be provided with physician oversight. This chapter provides a definition and explanation of a change in condition.

When a patient experiences a change in condition, it is a pivotal time. Negative changes from the patient baseline can frequently indicate the patient is “at risk” and may result in the need for urgent care. Recognizing the changes and effectively communicating these changes may help the patient stay in their preferred care setting – their home. This chapter reviews tools and other strategies for identifying change in condition.

While in home care, there are a number of critical times where patient’s may be “at risk” from a lack of clarity or communication related to their status. These may include changes in care settings, such as a transition from one care setting to another, changes in clinicians (“hand-offs”), change in the environment of care (after a fall or other incident), and other untoward findings or incidents that place the patient’s health at risk. A patient case scenario will be demonstrated for process review.

Documentation is a communication tool in itself. It tells health care providers what is happening with a patient at a point in time and over time. In addition to being the most reliable source of information, good documentation is for the health care providers protection as well. Sadly, nurses, therapists, and other team members are not immune from judgement or lawsuits. The best protection is appropriate documentation of both the change in condition and the communications following the observed changes. This chapter will review models that can be used to document changes in patient condition.

From legal to logistical, many definitions of family exist. This chapter will explore traditional to current definitions of family as well as other terms and cultural considerations that are used to describe living arrangements. Recent demographic and census data about living situations will be shared along with reasons for the shift in views about the composition of families and the potential implications of these changes on home care and hospice agencies.

While the composition of families has changed through the years, the functions and developmental tasks of families have remained constant. In this chapter, the focus will be on the health care function of families, how families help members return to their prior level of function after an illness, and the crucial role family plays for members to live safely in the community. Resources for families who are caregivers will also be discussed in this chapter. An interview with home care staff will facilitate the discussion about the importance of the relation between family members and home care and hospice staff.

What is a usual or expected home visit? What is the norm in a home? Answers to these questions and preparation for home visits will be discussed in this chapter.

Preparing for and responding to unexpected situations that can be encountered during a home visit will be proposed in this chapter. Examples from home care and hospice practice and a sharing of lessons learned from unusual home visits will be utilized to demonstrate the concepts presented in this chapter.

Patient safety is an important consideration in every home visit. When home care and hospice staff are confronted with unexpected findings during a home visit, how do they determine the boundary between patient and family rights and an unsafe situation? In this chapter, case scenarios will assist learning about that safety boundary and steps to take should an unsafe situation be found in making a home visit.

An introduction to the concepts of professional presence and professional boundaries will be provided in this chapter as well as the definitions of these terms that will be used throughout this course. Connections between concepts, behavior, appropriate relationships with patients and other members of the health care team, productivity, and personal safety will be discussed at length. Workplace, legal, and professional issues in relation to professional presence, boundaries, boundary crossings, and boundary violations will also be discussed.

Through discussion and images reinforced by examples and stories, this chapter looks at the “Three S’s” approach to attire. The “Three S’s” of Show Respect (dress for the occasion), Shift Focus (from you to the patient and/or family), and Safety (personal injury and personal safety), will be explained in relation to their significance in selecting a wardrobe for home care work settings. This approach can be utilized by all members of the home care team, from direct care providers to office staff to management.

The act of visiting a person in their home can produce an atmosphere of using personalized conversation. A patient’s desire for staff to use a personalized style can produce difficulties with the balance between personal and professional language. This chapter will utilize the “Three S’s” approach to identify examples where professional presence and professional boundaries are enhanced with elements of language.

How one goes about their day provides an opportunity to establish professional boundaries and avoid boundary crossings. A person’s attitude is an important element in how one goes about their day. In this chapter, a question and answer format will be used to highlight specific behaviors that originate from using the "Three S’s" approach when focusing on attitude. This approach assists in creating positive relationships and minimizes opportunities for boundary crossings, e.g., gifts, loans. Real life examples of how this approach promoted personal safety will also be shared.

The Conditions of Participation are requirements by law for participation in the Medicare program. This first chapter will discuss the Medicare participation glossary and what it means to clinicians and managers. Special emphasis will be given to CoP 484.55, the comprehensive assessment of patients.

his chapter describes how to effectively set the stage for successful data collection, with special emphasis on the home environment, beginning the professional relationship milieu, and explaining the process of the comprehensive assessment to the patient/family/caregiver.

This chapter reviews best practices related to performing a physical assessment in the home setting. Effective individualization of care is predicated on assessing the patient’s unique home environment. Areas for emphasis include infection control and prevention, family caregivers, and safety in the home environment.

This chapter emphasizes the importance of accurate and detailed information collection. Active listening, observation, and assessment, along with other strategies, are presented to assist in effective patient care planning.

This chapter pulls together the prior chapters to demonstrate the creation of an effective care plan. This includes the prioritization of problems, including the risk points for rehospitalization, providing the findings, and working with the patient and family to determine patient-centered goals for care. A patient example of Mrs. Sammy will be presented.

The term "case management" is utilized in home health to describe a method of oversight that is practiced to effectively manage patient care episodes. This method focuses on the ability to accurately assess the acuity of home care patients as well as the ability to provide and coordinate high-quality care that appropriately meets the patient's needs. The case manager is responsible for managing multiple patients holistically and across time, and this concept provides the framework.

The provision of patient care in the home can at times be a daunting task. Providing care in the home requires a specialized skill set that includes experience in clinical practice, leadership skills, strong reasoning and decision making skills, organizational skills, and more. As one can imagine, the home care practice setting is not for everyone. In this chapter, we examine the desired attributes of a case manager and the scope of this very important role.

There are many aspects of care that must be managed throughout the course of a patient episode. This chapter identifies the specific areas that require close supervision, oversight, and management. A patient example is shown to better illustrate these complexities.

Provision of patient care in home care is more than providing specific tasks to a patient. The patient must be considered/assessed from a holistic perspective, meaning the home care clinician is responsible for identifying not only patient medical problems but the problems associated with the environment in which the patient lives that may impact their ability to medically improve and successfully achieve desired outcomes. The home care clinician must develop an appropriate plan to support mutually agreed upon goals for improvement in the patient environmental situations that impact care as well as support improvement of their medical status. Once this individual plan is developed, it must be managed. The individualized patient plan of care is the road map clinicians utilize to assure that the care is managed effectively across all disciplines. This chapter looks closely at the aspects of patient care that must be carefully managed.

Successful caseload management is directly related to the organizational skills of the case manager. This chapter discusses organizational strategies and tips to support effective caseload management. There are different models for the organization or oversight of care management. Some of the ways to effectively manage caseloads will be presented and explored.

Healthier, happier patients and community can have a lot of benefits, including improved clinical and financial outcomes. This can lead to better relationships with referral sources and physicians. This chapter discusses the ways positive case management can impact home care.

The foundational knowledge of coordination of care and services is paramount to achieving positive patient outcomes. The Centers for Medicare and Medicaid Services (CMS) has established this as one of the riskiest areas for patients and have made it a Condition of Participation. In order to participate and receive payment under the Medicare and Medicaid programs this condition must be met.

This chapter highlights key strategies that have the potential to improve the effectiveness, safety, and efficiency of home health systems. Care coordination that is well thought out and outcome-oriented can improve results for patients, providers, and payers alike. The Care Coordination Measurement Framework from the Agency for Healthcare Research and Quality will be introduced.

This chapter discusses best practice methods that are utilized throughout the United States. CMS requirements and recommendations from the Agency of Healthcare Research will be used to identify interactions, activities, and processes to include in effective coordination of care and services. These are specific actions taken in the delivery of care, such as communication and assessing needs and goals.

Applying information and mechanisms for establishing quality care coordination to achieve interdisciplinary goals is a win for all involved. The patient, the agency, and the clinical staff reduce risk and negative outcomes with united measurable goals. This chapter explores how to establish and achieve interdisciplinary outcome-oriented goals to improve patient outcomes.

What must be documented to demonstrate effective coordination of care and services and meet regulatory requirements will be discussed. The timing of documentation and what is documented are both important to demonstrate regulatory compliance, receive payment for services, and show effective care of the patient. This chapter seeks to educate to achieve success in documentation.