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Orientation: An Overview of Documentation Requirements in Home Care

presented by Kim Corral and Tina Marrelli

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Disclosure Statement:

Financial: Tina Marrelli is an employee and share holder of Marrelli and Assoc. Inc, with book sales. Tina Marrelli is  a share holder with book sales of Innovative Caregiving Solutions LLC. Tina Marrelli is an author who receives book royalties from Sigma Theta Tau International Publishing. Tina Marrelli receives compensation from MedBridge for this course. Kim Corral is an employee and share holder of Chelta, Inc  Kim Corral receives compensation from MedBridge for this course. For both instructors there are no financial interests beyond the production of this course.
Non-Financial: Tina Marrelli and Kim Corral have no competing non-financial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact support@medbridgeed.com. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

Accreditation Check:
Today's home care clinicians must have an understanding of the trends, regulations, and other external factors that impact care provided and the documentation surrounding care. Home care is a global term, and home care services can range from solely personal care services (non-medical) to very skilled levels of care with licensed nurses providing care to medically fragile adults and children. Because of this, there are many models and methods of delivering home care. For purposes of this course, we will be focusing primarily on the provision of “visits” as the primary model of home care vs. hourly care. Medicare is the largest payer of home health services, and visits are the usual unit of care delivery. Medicare sets the standards for home care, regardless of the payer. It is for this reason that an overview of documentation requirements is the first course. The differences in documentation requirements for home care versus other settings (e.g., OASIS) will de discussed, and the purposes of documentation, supporting medical necessity, and coverage criteria will also be addressed. This course is designed to provide tangible tools for both clinicians and leadership/management to apply as they improve their processes and practices related to effective documentation in home care.

Meet Your Instructors

Kim Corral, RN, BSN, MA Ed, COS-C

Kim is a registered nurse with a master's degree in education and more than 30 years of home health experience. She is an experienced leader in home health care, having held both clinical and operational positions at regional and national levels for large corporate home health organizations. She brings a passion for providing the clinical…

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Tina Marrelli, MSN, MA, RN, FAAN

Tina Marrelli is the president of Marrelli and Associates, Inc., a publishing and consulting firm working in home care for more than 30 years. Tina is the author of 13 books, including the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (6th edition, 2018). Other books include A Guide for Caregiving: What’s Next? Planning…

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Chapters & Learning Objectives

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1. Welcome to Home Care and Home Care Documentation Requirements

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.

2. The Purpose and Multifaceted Roles of Home Care Documentation

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.

3. Why All the Scrutiny and Oversight of Home Care Documentation?

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.

4. A Patient Example with an Assessment

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.

5. Value of Documentation of the Plan of Care from a Number of Safety, Quality, and Payment Perspectives

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.

6. Fundamentals Remain: The Numerous Roles Documentation Plays in Effective Patient Care and Care Planning

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.

More Courses in this Series

Welcome to Home Care: An Overview

Presented by Kim Corral, RN, BSN, MA Ed, COS-C and Tina Marrelli, MSN, MA, RN, FAAN

Welcome to Home Care: An Overview

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
This foundational course offering provides a big picture overview of home care. Home care comprises many models of care delivery systems and types of home care. A brief history of home care, a snapshot of where we are now by the numbers, and the differences between home care and any other health care practice setting are addressed. A holistic and practical definition of home care is also presented. Additionally, this course will also explain why having exemplary clinical, self-motivational, organizational, and people skills is key to success in home care practice and management.

View full course details

Orientation: Care Planning

Presented by Kim Corral, RN, BSN, MA Ed, COS-C and Tina Marrelli, MSN, MA, RN, FAAN

Orientation: Care Planning

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The ability to perform an accurate comprehensive assessment and develop an individualized plan of care for home care patients is the foundation for care delivery in home care. This course will review the steps of the care planning process, a type of problem solving method. A discussion will be provided regarding the application of this process and the value it brings to patient care.

View full course details

Orientation Program: Team Member Safety in the Community

Presented by Kim Corral, RN, BSN, MA Ed, COS-C and Tina Marrelli, MSN, MA, RN, FAAN

Orientation Program: Team Member Safety in the Community

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
This course addresses the common safety-related factors in the community and home environments. Home care team members can be exposed to a number of potentially serious hazards which range from dangerous pets (eg. biting) to firearms (ie. guns) in homes. Environmental hazards include smoke, needlesticks, unhygienic homes, germs and pathogens, structural house problems, hoarding and many others. This course seeks to identify some of these safety hazards and dangers so that clinicians and managers/leaders can better understand and apply their risk management and safety policies related to such situations and protect their team members.

View full course details

Medicare Coverage and Documentation Requirements: The Fundamentals

Presented by Kim Corral, RN, BSN, MA Ed, COS-C and Tina Marrelli, MSN, MA, RN, FAAN

Medicare Coverage and Documentation Requirements: The Fundamentals

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The value of the clinical documentation that supports the tenets of coverage and quality cannot be overstated. Clinicians and managers/leaders need to proactively describe care and services in the terms detailed in the Medicare Benefit Policy Manual, Chapter 7. This, then, is the guidebook when seeking answers, examples, and clarity. This overview describes the fundamentals of Medicare coverage and the associated required documentation to support medical necessity, the individual patient's need for the skilled care and service, and the tenets of the home care program.

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What is Case Management in Home Care?

Presented by Kim Corral, RN, BSN, MA Ed, COS-C and Tina Marrelli, MSN, MA, RN, FAAN

What is Case Management in Home Care?

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
The home health industry demands that patient care be provided in an efficient and effective manner. Case management is a strategy which supports this demand. This course defines the concept of case management and discusses the skills and core knowledge concepts required to manage not only individual patient episodes but entire caseloads of patients. Strategies for applying this process to individual patients and caseloads will be discussed with practical examples that can be applied in the care practice setting.

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How to Make an Effective Home Visit

Presented by Kim Corral, RN, BSN, MA Ed, COS-C and Tina Marrelli, MSN, MA, RN, FAAN

How to Make an Effective Home Visit

Subscribe now, and access clinical education and patient education—anytime, anywhere—with video instruction from recognized industry experts.
This foundational course addresses the three parts of the patient home visit and information and processes that surround and support effective and holistic home visits. This includes a practical and holistic definition of a home visit, the use of the care planning process through the visit, the patient-related and other activities that occur during a skilled visit, and strategies to document care that was provided during the visit. This course will also explain why having exemplary organizational, clinical, and interpersonal skills is key to making value-based home visits. This is because numerous and complex facets of care, including the patient's goals, the plan of care, physician orders, care team members, the patient's environment, care coordination, and communication, all come together in this structured, person-centered encounter.

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