Transcript Covenant HomeCare (2).

Covenant HomeCare
Purpose Statement
To help people live with comfort,
dignity, and independence.
Instructions
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Complete the five Educational Modules for Infection Control,
Hospital Safety, Patient Diversity, Safety Goals and Age Specific
Care
Complete the five educational modules quizzes with a score of
80% or better
Complete the HIPAA 101 Training Module
Read information provided about Covenant HomeCare
Print a copy of your quiz results
Print, read and sign the Confidentiality statement
Print and sign the HIPAA Training Documentation Form
Print and sign the Acknowledgement to Ride Form
Give post test results, and all documentation forms to your
instructor
Philosophy
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Covenant HomeCare is dedicated to satisfying
and educating both our customer and our
employees. We strive to meet our purpose
through innovation with the use of technology
and advanced treatment methods. It is our
continuing goal to advance home care as a
highly respected healthcare service. We are
committed to providing excellent healthcare in
this era of rising costs by using our
community’s resources wisely. Our
commitment to excellence has produced an
outstanding team of professionals dedicated to
our purpose.
Eligibility for HomeCare Services
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Must be homebound (confined to the home for
physical or psychiatric limitation.
Must be under a plan of care established by the
physician
Requires skilled nursing services on an intermittent
basis (occasional, short visits) and/or physical therapy,
speech language pathology, or a continuing need for
occupational therapy
- we also offer social work, psychiatric nursing, home
health aides, and chaplains.
Note: Some exceptions may exist based on
insurance/payor.
Other Services Offered by
Covenant HomeCare
Hospice
Hospice provides supportive and palliative care for a
patient approaching the end of life. To be eligible, the
patient must have a life expectancy of six months or less,
assuming the disease follows its natural course. The
primary emphasis is on controlling or preventing pain and
other symptoms. Our goal is to keep the patient as
comfortable as possible.
For Hospice services we offer skilled nursing, therapy (for
palliative measures only), home health aides, social
workers and chaplains.
Triage
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Our offices are open Monday through Friday between
the hours of 8 AM and 4:30 PM, but our staff are
available to the patient and family 24 hours a
day/seven days a week. When calling the office “after
hours” or on the weekend, a Triage nurse is available
to assist the patient/family with their needs. Hospice
patients are given the option of talking to the on-call
nurse. If further assistance is needed, the appropriate
individuals (Clinical managers, etc) are notified.
The Triage department also obtains lab results and
faxes these to the appropriate physician.
Scope of Covenant HomeCare
We strive to provide the highest quality
patient care with the use of technology
and advanced treatment methods. Our
staff uses laptop computers for
documentation to enhance our ability to
keep patient information current and
confidential. This technology enables
our staff to easily access current
homecare information.
Telehealth Program
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Telehealth is a home communication program, using a
device known as a “Care Health Buddy”, that is used
to increase patient outcomes, prevent hospitalization,
as well as increase patient knowledge and compliance
in self management of Congestive Heart Failure and
Diabetes.
 It provides 2 way communication by securely
collecting and transmitting important & timely
information on a patient’s chronic condition
 It provides education, prompts actions & helps identify
risks
 A screening tool is used by the clinician in the field to
determine if the patient is appropriate for the
Telehealth program.
How does Telehealth work?
The device asks a series of questions to
the patient about their disease
 It instructs & reinforces important health
management information
 It measures with Medical Devices
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B/P cuffs
 Scales
 Blood glucose monitors
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Privacy
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Personal health information is shared
only with those necessary to provide
appropriate care and maintain
compliance with state and local
regulations. This may include
physicians, payors, regulatory, and
accreditation agencies.
Appearance Standards/Dress Code
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Dress in a professional manner
No Fragrances
No Dangling Jewelry
No visible body piercing except earrings
No earrings except in the ear lobe
No more than 1 ring per hand
No visible tattoos
No fingernails beyond the tips of the fingers
No artificial nails
No general lack of cleanliness or general grooming
OASIS ASSESSMENT
We are required by Medicare and
Medicaid to do a complete assessment
that accurately reflects the patient’s
current health and includes information
that can be used to show the patient’s
progress toward their health goals. This
is the “Outcome and Assessment
Information Set” (OASIS).
Time Points for Completing an
OASIS assessment
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Start of Care (SOC)
- must be completed the same day as the SOC date (which is the first billable
visit)
Recertification
- within the last 5 days of each 60-day period after SOC
Discharge from Homecare
- must be completed within 48 hours of agency knowledge of the event
Transfer to Hospital
- Transfer to an inpatient facility for a period of 24 hours (or more) for any reason
other than diagnostic testing. Must be completed within 48 hours of the event
occurrence.
Resumption of Care (ROC)
- after the inpatient stay. Must be performed within 2 days of hospital discharge.
Significant change in Condition (SCIC) = Follow-up Survey
- must be performed within 2 days of a significant change in the patient’s
condition. This is an unexpected improvement or decline in a patient’s condition,
such that a change in the plan of care is necessary.
OASIS Hierarchy Level
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When more than one discipline is in the home, the Start of Care (SOC),
Recertification or Follow-up Surveys (SCIC) are completed according to
the following hierarchy :
- RN
- PT
- SLP
 Disciplines remaining in the home at the time of recertification complete
the Recertification OASIS survey according to the following:
- RN
- PT
- SLP
- OT
If the RN is in the home twice a month or less, the RN may request a more
frequently visiting discipline to complete the OASIS Recert hierarchy.
The first skilled discipline in the home at the time it is determined a follow-up
is needed will complete the Follow-up OASIS.
HomeCare
Coordination of Care
Before Admission
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When a patient is referred to home health, all pertinent
information is entered on the referral form by Central Intake
and an identification number is assigned.
Transition of care from the hospital to the home environment is
most frequently accomplished through the efforts of the hospital
Discharge Planner (i.e., Social Workers, HomeCare Coordinator,
etc.) who initiates and maintains communication between the two
entities.
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If the patient is in the hospital, the HomeCare
Coordinator/Discharge Planner will review the hospital record
and initiate a visit with the patient and family. The purpose of
the review/visit is to identify any home care needs and verify
that the needs fit the guidelines of HomeCare/Hospice
Services.
If the patient is already at home, the person taking the referral
will find out the date of patient’s last hospitalization
Admission Criteria for Home Heath
and Hospice
• Determination that the patient's health needs can be adequately met in
their home environment including a plan to meet medical emergencies and
that such care is more desirable in promotion of the patient’s health interest
than any other kind of service would be.
•Willingness and ability of primary caregiver to provide care in the home
and acceptance of the program by the patient/family (as appropriate).
•The patient has a primary caregiver or agrees to secure one or seek care
in an alternative facility when self-management is no longer possible.
•Patients are admitted without regard to race, creed, color, age, sex,
national origin, handicap, religion, gender preference, or marital status.
•Residency within the Agency’s geographic coverage area.
• For Home Health, patient has a payor who is under contract with Agency
or elects to pay privately.
•For Home Health, physician certification that patient has a need for home
care services. (For Medicare: patient must be home-bound and have a
need for at least one skilled service).
Specific Admission Criteria for
Hospice only
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Diagnosis of a terminal illness, with a limited
prognosis, and an informed decision to shift
goals of treatment from curative to palliative
therapies. The focus is on maximizing the
quality of remaining life
 Physician certification of the appropriateness
of hospice care based on the patient's limited
life expectancy and patient/family therapy
goals
 Patients/legal guardian is aware of terminal
prognosis and desires Hospice Services
Central Intake
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Initial referral information is entered,
including referral orders, with insurance
verification and pre-authorization completed
as applicable.
If the services of other (internal) disciplines
are requested, notification of the referral and
anticipated admission date is given to the
ordered discipline.
External referrals are made and coordinated
for all services not provided by the Agency.
Scheduling/Admission
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Services are scheduled in advance to assure
planned, organized, and coordinated care.
Patients are involved in defining a
convenient day and time for receiving
services.
Assignment of staff for patient visits is based
on identified patient needs, staff knowledge,
experience, competency, and infection
control issues. Attention is given to
consistency in staff assignments.
Pre-Planning
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All staff members providing direct patient
care review the contents of the clinical
record of all assigned patients in
advance of the scheduled visit. The
review is comprehensive in nature and
includes the documentation of all
disciplines rendering care. This review
alerts the staff member to any changes
in patient condition, treatment, orders,
etc.
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The admitting clinician telephones the patient to arrange
the initial visit (to occur within 48 hours of the
referral/hospital discharge or Physician’s Order).
The Clinician obtains directions to the
patient’s home.
At the time of the visit, the admitting clinician
involves the patient/primary caregiver in the
development of realistic and attainable goals.
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Care Coordination
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There is ongoing communication between
the Agency staff and the patient’s Physician,
or between the hospice interdisciplinary
team and the patient’s Physician.
Communication is accomplished in person,
by letter, fax, or telephone at a frequency
indicated by changes in
status/caregiver/environment or at least
every 60 days.
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Communication includes:
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The patient’s current condition.
Changes in the patient’s condition.
The outcome of care and service.
The patient’s response to current treatment and
medication.
Changes in caregiver support or the environment.
Results of relevant laboratory tests when they
become available.
Omitted visits.
During Admission
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At admission, the patient/caregiver is informed of the following:
Agency hospital relationship
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Patient financial responsibility
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Scope of services
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Mission/Vision
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Patient/family rights/responsibilities
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Complaint procedure
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Procedure to follow in emergency
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Safety precautions
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State, Medicare, CHAPS hotline number
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Agency’s procedure for resolving conflicts of care and ethical issues
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Advance Directives
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Availability of staff, 24 hours/7 days/week, and telephone numbers to
call
The clinician explains, reviews, and witnesses signing of informed consent,
and at this point assessment is completed in accordance with Agency policy
and procedure.
Visit documentation is entered on the laptop: Clinical Note, supply charges,
time record, etc. is completed with accuracy and communicated timely.
Other disciplines requiring a visit into the patient’s home will contact the
patient to establish a visit schedule.
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To achieve care or service goals, there is
ongoing communication with the patient,
identified caregivers, and other staff providing
care or services. This is necessary to address
changes in the patient’s needs, goals, care or
services to be provided, and Physician’s Orders.
Communication is:
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Appropriate to the patient’s needs and abilities.
Inclusive of all staff providing care.
Relevant to care or services provided.
Timely.
Before Discharge
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The discharge process is initiated on the admission visit and is
ongoing throughout the patient’s care. As continuing care needs
are identified appropriate referrals are made.
Patients are periodically assessed for appropriateness of
continued home care services (ex: Interdisciplinary Care
Conferences, Recertifications, Audits, etc.).
As the patient’s home care needs decrease, greater attention is
given to preparing the patient/family for ongoing management of
care post-agency discharge (ex: Community Referrals).
All patients receiving “terminal care” must have a completed
Survivor Risk Assessment prior to death. This is useful in
determining bereavement needs.
Decisions regarding the provision of ongoing care and/or
discharge is based on the care required by the patient.
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If continuing services are medically necessary, care will continue as
established. If care is no longer covered by insurance, patient will be
notified and alternate reimbursement will be arranged.
If continuing services are not medically necessary, plans for discharge
or other arrangements will be facilitated.
Discharge Criteria
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The attending physician has determined that maximum benefit to
the patient has been achieved.
The patient becomes physically able to obtain needed services
on an outpatient basis.
The patient's clinical status worsens and hospitalization or
nursing home care becomes more appropriate.
Patient or family requests that services be discontinued and this
request is sanctioned by the attending physician
Patient expires
Hospice bereavement - period of 13 months has elapsed.
Patient or responsible person demonstrate noncompliance on
ongoing basis.
Patient has relocated to a geographic area not covered by the
Agency.
Patient revocation of Hospice.
Discharge Criteria cont…
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At the time of patient discharge/transfer/referral
relevant information is provided to receiving
organizations and/or the physician to facilitate
meeting of the patient’s continuing care needs.
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The patient is discharged to self or significant
other responsibility when discharge criteria is
met.
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The patient is transferred to an in-patient facility
when one of the following criteria is met:
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Patient’s condition has become severely acute;
treatment plan objectives are not attainable in the
home.
Acute threat to the patient/caregiver’s health and
safety is present.
Patient and/or responsible party are consistently
non-compliant with the treatment plan despite
documented teaching/counseling.
Patient still needs medical attention but the home
has become an unsafe environment for the
patient or the branch’s caregivers.
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The patient is referred to other providers when
one of the following criteria is met:
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Patient/family/physician request.
Patient still needs care, but moves out of geographic
service area of the Agency.
Patient requires services that the Agency is unable to
provide.
Patient is referred to a “Preferred Provider” if Agency is
determined not to be a “Preferred Provider” for a
specific commercial payor.
Discharge/Transfer cont…
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Written information relative to discharge or
transfer of patient, such as a Transfer or
Discharge Summary, is forwarded to other
providers assuming the patient’s care
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Copies of the Discharge Summary are sent to the
physician upon physician request. The Discharge
Summary includes:
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Date of discharge
Reason for discharge
Status of problems identified throughout the course of care
Patient’s overall status
Summary of care or services provided
Termination of the Hospice
Medicare Benefit (HMB)
Hospice patients are no longer under the HMB in 3 situations:
Discharge
Revocation of the HMB
Death
A Hospice can discharge a patient from the HMB for the following reasons
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If the patient is determined to no longer be terminally ill.
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If the patient moves out of the Hospice’s geographically defined service area.
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If the safety of the patient or of the Hospice staff is compromised. The
Hospice must make every effort to resolve these problems satisfactorily
before it considers discharge an option.
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If the patient enters a non-contracted nursing home and all options have
been pursued (a contract is not obtainable, the patient chooses not to
transfer to a facility with which the Hospice has a contract, or to a Hospice
with which the LTC has a contract), the Hospice can discharge the patient.