by Tina Marrelli
[Author’s Note: Many clinicians ask about care planning and the related clinical and operational processes. As the author of the Handbook of Home Health Standards: Quality, Documentation, and Reimbursement (also called the “little red book”), the topic of documentation and care planning is one close to my heart! I hope that by the time you have finished this article, you are convinced of the value of effective care planning and how the care plan—what used to be called the 485—is where “the rubber meets the road!” The care standards of the “red book” have been incorporated into the new web-based software to improve care planning and compliance. Comments or thoughts can be directed to Tina Marrelli at email@example.com]
As the complexity of home care and the patients/consumers served have also become more complicated, often due to chronic conditions, it is easy to feel overwhelmed and like we “forgot to document something.” Believe me, I too have suffered from this syndrome. The complexity does not mean we are forgetful or “not good enough,” it is truly driven by the numerous factors—too numerous for one brain to remember!
I was very heartened (and you might be too!) when someone gave the book The Checklist Manifesto: How To Get Things Right by Dr. Atul Gawande. The basic premise is that, like a surgeon or an airline pilot, there are just too many tasks for even expert professionals to remember, and to remember every time! Hence, checklists have emerged as lifesavers. Think of when you are at the airport and there is a pilot walking around the jet with a clipboard making observations and writing on it. In the riveting stories in Gawande’s book are healthcare examples that make me feel better as I now understand the importance of that clipboard and checklist in places like the operating room where they work for safety and other hardwired improvements.
I mention this as an example of a way we need to look at home care—and especially home care planning and documentation. Like aviation and the surgical areas, there is just TOO much to remember. If the whole premise of what we do is to “get things right,” what better way than to standardize the complex and detailed world of care planning and documentation? And if the care planning is accomplished effectively at the “front end” when completing assessments, for example, then the documentation should similarly be detailed and accurate. And, as important, we do not have to keep it writing it in different places!
Let’s look at two examples.
It is known that there are certain findings or evidence that lead to improved patient (or other) outcomes. One is that “frontloading” for heart failure patients works (and not for other patients, but that is a discussion for another day). Another is that those patients that have a doctor visit within a certain number of days of discharge from the hospital seem to not come back within 30 days for another admission. There are many of these evidence-based or “best” practices that, taken together, can make meaningful impacts on our patient’s lives and those of their families/caregivers.
The exciting thing is that we now have the tools to incorporate such items into systems to support improvements in clinical workflow and help us in our quest to provide the “best” care and also to achieve the “best” outcomes. We know that proven or evidence-based practices generally produce better patient outcomes. The following mnemonic for C-A-R-E-P-L-A-N addresses what we need to know and do to effectively meet numerous regulatory and other requirements and provide the best of patient/family care. And the good news is that the best systems support these tenets.
C: “Covered” Care Criteria—This refers to the Medicare and other payer’s specific criteria, such as a qualifying criteria to pay for care. This includes the Medicare Policy Sections that describe “Coverage of Services,” such as that the person be an eligible Medicare beneficiary, the home health agency participates in the Medicare program, that the beneficiary qualifies for coverage, that the care is reasonable and necessary, the patient is homebound, etc. There would be similar or other specific language for state Medicaid or other payers/insurers.
A: Assessment—Assessment is the first step in the nursing or scientific process and becomes the driver for all care and care-related processes. In home care, the assessment is multifaceted and the OASIS is (one) part of the patient’s comprehensive assessment. The assessment findings and the critical thinking components that are generated from the assessments and the objective collected data and other findings then become active parts of the plan of care (POC). The POC is sometimes thought of as (solely) the 485 form—or, more specifically, the data items on the form—but the POC is a “moving” plan in that it changes as needed.
This could be because a new medication is ordered (so the verbal or telephone or interim order) and becomes incorporated into the plan of care. Another example is that the patient falls, is not injured, the doctor is contacted, physical therapy and occupational therapy are ordered for assessments, and then strengthening, gait training, balance, and other interventions and care are instructed.
R: Reason for Care and Critical Reasoning—Insurance companies, such as Medicare (federal) and Medicaid (state based) pay primarily for skilled services. Exceptions to this general rule include specialized waiver and other programs, such as those for pediatrics and others for frail elders. The reason that a person is admitted to home care — and has a medically necessary reason or skilled “need” — should be identified after the data is collected, analyzed, and the “reason” is identified and the critical thinking or clinical “reasoning” is completed.
In nursing processes, this is where “diagnoses” and problems are identified. At its most basic, this is the analysis of the findings and putting the puzzle together for a complete and effective patient plan of care. This then becomes the basis for all care and documentation.
It is the single source document for which care, interventions, and medications (including OTC and creams and herbs) need doctor orders. Once the reasons or diagnoses/health problems are identified, the goals or outcomes that are desired are also identified. And, as important, this then becomes basis for all clinicians on the home care team as they seek to help the patient meet their identified goals going forward.
E: Evaluation of Care—After the patient is admitted (as described above) and the assessment was completed, if the patient meets coverage criteria and the POC has been discussed and confirmed with the ordering physician, it becomes clear whether the care is working (helping the patient meet the predetermined goals or outcomes) or not. If the plan is not working, it might require more time to show results or a team meeting may be needed to address the plan (sometimes the team can see things that one person cannot).
Sometimes another or a new problem might take precedence and those become the focus. An example is that the patient was admitted to home health care with heart failure and the office gets a call that the patient was admitted to the hospital with an exacerbation of chronic obstructive pulmonary disease (COPD).The family took her to the emergency department for asthma treatment. When the patient is discharged back to their home, it may be that breathing treatments, new medications, the exacerbation of the disease, oxygen safety, and the assessment of lungs and other problematic symptoms related to her COPD and hospitalization for asthma would become the new priorities for care and related interventions.
This is where the nursing or scientific process continues as a cycle—(further) assessment, identifying problems/diagnosis, expected outcomes/goals, further planning, implementation, and, again, evaluation.
P: Pre-Visit, Visit, and Post-Visit Activities—These activities represent a home care team member’s day. The more systems can “think” how we process and plan care, the better it will be for the standardization of care and related processes. For example, in the pre-visit there are the orders that must be obtained and documented prior to care, such as the details related to the patient’s location, directions, pets, parking availability, and numerous other things that can take longer than the visit sometimes! Reminders about calling the patient and family and seeing how the patient is “doing” can sometimes save a day. For example, this might save a drive to the patient’s house if the family reports that another family member has driven the patient to the emergency department after they were not feeling well. These seemingly “small” systems reminders can help save valuable time and scheduling tasks.
During the actual visit, you have the capability to review that your care plan is consistent with your assessment and that you have access to and can complete more detailed assessments (should you wish to) at your fingertips. This is a great thing. For example, if your new patient has pain, you can identify and complete a very specific plan. Similarly, if your patient reports a history of falls (and we know that past falls are an indicator of a greater risk for falls), you can identify and complete a detailed fall risk assessment tool and communicate this important safety information to other team members who might also be caring for this patient (such as the physical therapist and the home health aide).
This depth for further assessment and tools is similarly available for nutritional risks and other areas, again, all based on your patient and the needs you identify as requiring further, or a more detailed, assessment. The review of the orders for accuracy is a first step and this becomes your map for care against which the documentation occurs/supports. There is a library of information that is multidisciplinary to help provide guidance and reminders as needed. As noted in the beginning, a checklist or other tool is a very good thing when the complexity and detail can no longer be safely managed solely by memory. Documentation of the visit while onsite is a known safety and quality standard. Unless it is a safety concern, the more that the specific findings and documentation get completed in real time the better. Create the plan for the next visits and schedule the visits based on the patient need.
Post-visit activities can also be time consuming and are no less important. Examples might be completing missing data, such as the daughter’s phone number; following up with the physician when you are unable to reach them from the patient’s home; clarification of orders; verification of medications; scheduling or verifying the next physician visit with patient/consumer and family; contacting other services or disciplines based on the findings from the home visit; and more.
One that I think is very important is trying to step back and look at the patient’s documentation and review it for clarity and with “new eyes.” Ask yourself, did it tell the story and paint the picture of the patient you just visited? Consider if you fell and broke your leg or otherwise could not go to work/make visits for a few days or weeks—would your colleague(s) be able to know that your patients “look like” and need based on the clinical documentation and the care communication/coordination notes? Are the schedules of who else comes and when clear? Is there a medication reconciliation of the medication sheet left in the home? Is there a calendar so that patient (and others) know who is to be visiting and when/next? All these important “details” must be documented and timely to support the team and safe patient care.
L:Learning—In all aspects of health care generally, and home care specifically, there are many aspects of care that patients and caregivers need to learn. One of the longest sections in the “Coverage of Services” section from the Medicare Home Health Agency Manual is the skill that defines and lists “Teaching and Training Activities.” The section begins with “Teaching and training activities that require skilled nursing personnel to teach a patient, the patient’s family, or caregivers how to manage the treatment regimen would constitute skilled nursing services.
Where the teaching or training is reasonable and necessary to the treatment of the illness or injury, skilled nursing visits for teaching would be covered. The test of whether a nursing service is skilled relates to the skill required to teach, and not to the nature of what is being taught.” (emphasis added by author) (Centers for Medicare & Medicaid Services [CMS], 2015).
There are six patient examples listed for clarification of this information. It also states that “there is no requirement that the patient, family or other caregiver be taught to provide a service if they cannot or choose not to provide the care” (CMS, 2015).
There are 18 examples of teaching and training activities, but they are not limited to these examples. Included in that list of 18 examples is: “Teaching the self-administration of injectable medications, or a complex range of medications”; “Teaching wound care where the complexity of the wound, the overall condition of the patient or the ability of the caregiver makes teaching necessary”; and “Teaching proper administration of oral medication, including signs of side effects and avoidance of interactions with other medications and food” (CMS, 2015).
Because some medications are responsible for many emergency department visits and readmissions to hospitals (such as blood thinners and insulins), it is imperative that specific teaching and medication reconciliation occur.
Teaching is incorporated into most care. For another example, wound care and their products have made significant strides with care and there are new products to care for all kinds of wounds. When we learn, we teach, and this continues the cycle of quality and performance improvement in care. Whatever “skill” provided to patients in their homes, such as teaching, it is very important that we, as nurses, “get credit” for this and clearly document all the provided patient care. For example, in the wound area, there may be three skills provided during the course of the wound care. They could include:
A: Adaptation—Adapt the care plan to ensure that it serves as the map for each patient, leading to great outcomes and including their input. Adapt clinical practice in order to complete your documentation when possible in the patient/consumer’s home. There is just “too much” to remember from vital signs and history and skills that might be very detailed, including pain findings, g-tubes, infusions, wounds, and other special care. As mentioned in the introduction, there is just too much to remember and it all very important! So, of course, document as close to the time that the care was provided as possible.
N: Now—Now is the time for home care! As models for payment and quality move toward “value,” let’s show what we know! In case you sometimes get discouraged, here are a couple of quotes you might want to be aware of and share with others. The first is basic demographics, and these trends are worldwide. I was at the International Home Care Nurses Organization (IHCNO, www.IHCNO.org) meeting in Chicago and a speaker from Asia referred to this as the “gray tsunami.” According to the 2014 report commissioned by the National Institutes of Health (NIH), America’s older adult population is “now over 40 million and expected to more than double by mid-century, growing to 83.7 million people and one-fifth of the U.S. population by 2015”(National Institute of Aging [NIA], 2014). And not only are Americans living longer (and sicker) with chronic diseases but 10,000 Americans are also turning 65 every day from now until 2030 (Pew Research Center, 2010). Such numbers will not be decreasing anytime soon and more and more the setting for health care will be home.
Centers for Medicare & Medicaid Services (CMS). (2015). Medicare Benefit Policy Manual Chapter 7 - Home Health Services. Retrieved from http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf
National Institute of Aging [NIA]. (2014). NIH-commissioned Census Bureau report highlights effect of aging boomers. Retrieved from https://www.nia.nih.gov/newsroom/2014/06/nih-commissioned-census-bureau-report-highlights-effect-aging-boomers
Pew Research Center. (2010). Baby Boomers Retire. Retrieved from http://www.pewresearch.org/daily-number/baby-boomers-retire
©2015 by Tina Marrelli and Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article has been published in Tim Rowan's Home Care Technology Report. homecaretechreport.com by permission of the author. One copy may be printed for personal use; further reproduction by permission of the author.