presented by Tina Marrelli & Kim Corral
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.
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 for Safety, Quality, and Compassionate Care for Your Loved One and Yourself (2017), Hospice and Palliative Care Handbook (3rd edition, 2018), The Nurse Manager’s Survival Guide (4th edition, 2018), and the best-selling home health aide educational system, Home Health Aide Guidelines for Care: A Handbook for Care Giving at Home and its accompanying Nurse Instructor Manual. Tina served on the workgroups that defined the first hospice nurse standards as well as serving as a reviewer in 2014 for the revised Home Health Nursing: Scope and Standards of Practice through the American Nurses Association. Tina attended Duke University, where she received her undergraduate degree in nursing. She also has master’s degrees in health administration and in nursing. Tina has worked in hospitals, nursing homes, and public health, and has practiced as a visiting nurse or manager in home care and hospice for more than 20 years. Tina also worked at Medicare’s central office (CMS) for four years on Medicare Part A home care and hospice policies and operations as well as serving as the Interim Branch Chief for Medicare Part B. Tina loves policy and the nuances that frame care, practice, and delivery. Tina is an international health care consultant, specializing in home care and models of care provided in the community to people at home. Tina and her team of specialized consultants have been in business since 2002 and provide services related to the “design and implementation of challenges to providing home and community-based care.” In that capacity, they have served over 100 clients throughout the world, clients who represent varying segments of service to home care and/or related products. Services include custom presentations, software development, educational services, serving as Team Leader with a team that served as quality monitors to the OIG, accreditation services, new organizational start-ups, due diligence, feasibility studies, and more. Tina has been the editor of three peer-reviewed publications, most recently for Home Healthcare Nurse (now Home Healthcare Now), on which she served as the Editor-in-Chief for eight years. She is also an Emeritus Editor for Home Healthcare Now. In addition, Tina serves on the editorial boards of the Journal of Community Health Nursing and The American Nurse. Tina is the Chief Clinical Officer for e-Caregiving, www.e-Caregiving.com, a web-based support and educational system for family and friend caregivers created to support advocacy and improve care across the health care continuum.
Kim is a registered nurse, with a master's degree in Education, with over 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 voice of quality, while increasing efficiencies. She has extensive experience speaking for state home care associations, national home care organizations, and local home care organizations on regulatory compliance, successful strategies for clinical/operational success, OASIS data collection and strategies, quality outcome improvement, developing successful QAPI programs, documentation standards, and operational processes to support OASIS and ICD-10 accuracy.
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.