Many home health therapists struggle to complete documentation in a timely fashion and often find it to be a laborious task. The demand for home health care clinicians is growing at a rapid rate, challenging hiring managers to keep pace with the need. This course will provide seasoned home health clinicians with an opportunity to evaluate their current habits and offer guidance using actual, real life case studies to streamline their documentation time. For clinicians new to the home health setting, this course will translate Medicare regulation in understandable terms, instruct in a clinical reasoning process, and facilitate patient specific documentation that is audit ready.
Jennifer DeRosa, OT/L CAPS is the founder of AdaptABLE for LIFE, which originally provided in-home modification assessments and care coordination for older adults, however now focuses primarily on providing professional educational services. Jennifer graduated from University of New England with a Bachelor of Science in Occupational Therapy and earned a certificate in Gerontology from Salem State College. Jennifer has 20 years of extensive experience working throughout the continuum of care from the ICU, inpatient rehabilitation units, and home health settings both as a clinician and a supervisor. Jennifer is a recognized speaker and author on topics related to home and community health interventions and documentation. She is currently working on behalf of the American Occupational Therapy Association (AOTA) with the National Highway Traffic Safety Administration on authoring guidance documents for clinicians related to evaluation and treatment of driving competency in older adults. Jennifer also contributes to the web-based content and competency management product, Mosby Home Healthcare Collection. Jennifer is an elected member of the Professional and Technical Advisory Committee for Joint Commission representing AOTA as well as a member of the Home and Community Health Special Interest Section for AOTA.
In this chapter, Jennifer DeRosa discusses perceptions of documentation as being laborious and time consuming, highlighting the role that documentation plays in capturing the value and skill of services provided. Participants will learn the fundamentals of the Triple Aim in healthcare, and will come to understand the current healthcare climate and impetus for change.
Chapter two reviews the Medicare expectation of medical necessity, and introduces participants to the utility of the SBAR template for documentation of all patient encounters. Jennifer DeRosa will contrast components of the SBAR to the traditional SOAP note format, highlight the need for documenting skilled interventions and patient response to treatment, and discuss word choice tips that may be beneficial for documenting skilled interventions.
Join Jennifer DeRosa as she defines holistic care planning, elaborating on how client driven care can result in meaningful and unique outcomes. DeRosa will instruct in components of holistic outcome measures, describe effective use of “safely” as a meaningful outcome measure, introduce the FAST goals template, and will ultimately provide participants with the tools to conduct a self-reflection rate confidence rating on a scale of 1-10.