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.

Those 85 and older (the oldest old) have recently become the fastest growing segment of the United States population. Additionally, this age cohort has become the fastest growing segment of populations around the world. Yet, what is known about the oldest old? How has this cohort group achieved advanced age and remained able to live in the community? This chapter will provide an overview of pertinent background information about the oldest old age cohort, with an emphasis on those living in the community.

It has been said that change is inevitable. This is quite apparent as more years are lived. But what changes are specific to the oldest old? In this chapter, changes to physical body functioning and cognition will be discussed.

When does one become frail? What does frailty mean to one’s daily functioning? In this chapter, changes to one’s social environment will be discussed, focusing on frailty from a holistic, person-centered perspective. An interview with a member of the oldest old population will illustrate practical issues of the oldest old.

It is the goal of many to remain in their homes, living independently in the community until death. This chapter presents information about Medicare, as it is the largest payer of home care and hospice. Medicare has qualifying criteria, and it is important to be familiar with which services can be provided to patients and when. This includes aspects of coverage for ADLs and IADLs that aides provide to the oldest old.

This chapter presents a patient example to show assessment, management, and care planning considerations for the oldest old. Participants will also be given the opportunity to develop an individualized care plan for an older adult who is frail. For demonstration purposes, an exemplar care plan will be included.

How does the emerging science of caregiving inform best practices for these frail, at-risk elders? This chapter seeks to present information to help support these caregivers who live with and help their family member or friend remain in the community. Caregiving for those with non-cancer diagnoses can last for many years. This chapter goes over the caregiver statistics and initiatives related to caregiving, as well as what makes a good caregiver.

How are caregivers assessed and supported? What are some available resources? Home care and hospice organizations have an important role to play in educating and supporting these caregivers.

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.

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.

The mild or early stage of dementia is marked by a patient’s beginning losses of memory, language, instrumental activities of daily living (IADL) and changing mood. This chapter will cover the early warning signs and diagnostic evaluation tools for testing of Alzheimer’s disease and other types of dementia. Signs of what to look for during the onset of early-stage dementia and ways to promote person-centered care to enhance the patient’s quality of life will also be discussed.

This chapter will review common behavioral challenges often associated with mild and early-stage dementia and the impact these challenges may have on the patient’s quality of life. Strategies, tools, and approaches to address stressors and minimize behavioral symptoms will also be discussed.

Patients at home who have mild or early-stage dementia face increasing challenges related to functional ability, communication, and daily stressors. This chapter will review ways to support and educate the patient and family about safety.

It is never too early to start long-term planning for persons with dementia. In this chapter, strategies for long-term planning will be reviewed, as well as person-centered lifestyle management and self-care techniques to ensure success and enhance the patient’s quality of life.

A number of grassroots and governmental efforts are fueling the interest and support of family and friend caregivers. This foundational chapter discusses some of these efforts and their intrinsic value for home care and hospice clinicians and organizations. A number of state and federal initiatives and other caregiving-related models will be examined.

In this chapter, a practical and holistic definition of caregivers and the people they provide care for will be presented. In addition, the assistance or challenges that may present themselves when working with these important lay caregivers will be examined. How do educational priorities best get determined and addressed? What are the priorities, and why? The importance of the family caregiver’s role at the onset of care, e.g., during the assessment or initial visits, is also examined as a determinant of success in relationship building and as an important part of the clinician relationship or therapeutic milieu. These interactions can be integrated into an actionable part of the plan of care. A role-playing scenario will be presented to better illustrate such interactions as well as tips for success.

Competency in transferring knowledge and experience has never been more important. Shortened time frames in home care and hospice are examples. For cost, quality, staffing, safety and other reasons, family caregivers need to know enough to feel and be successful between and after visits and care. Adult learning principles and other tips for success will be provided.

This chapter addresses organizational, case management, and other skills needed for success to facilitate caregivers and goal achievement. The underserved family caregiver is shown as an activated and important member of the health care team. A case scenario will be illustrated to show best practices related to education and validation of knowledge and competency.