How to write a well-written care plan in home health and hospice

One of the many negative impacts of staffing shortages in home health and hospice is inaccurate or incomplete care plans, which can reduce or delay reimbursements. But an inadequately written care plan can do much more than affect your bottom line. It can keep patients from meeting their goals and cause more work for already overburdened staff.

In this blog, we explore the anatomy of a well-written care plan, why it supports patient-centered care, and how MatrixCare simplifies the process.

What is a care plan?

Care plans directly address the needs of the patient, family or caregiver and enable staff to provide the best services and environment for patients and families to meet their goals while receiving home health or hospice.

Care plans are working documents and need to be flexible based on patient progress or incidences. This approach helps to ensure patient-centered care is a priority.

What are the must-haves of a well-written care plan?

1. Guide care and provide a roadmap for the patient.

When the care plan is individualized to the patient’s needs and goals, staff can measure the effectiveness of care and record evidence that the physician’s orders were followed.

2. Show collaboration across disciplines.

Seamless communication between disciplines is critical to patient-centered care. The care plan helps to ensure patients will receive quality care regardless of which staff members provide it. This is important to consider, as agencies often have staff cover for each other during sick days or vacation.

3. Justify and support the need for services.

Care plans should provide insight into changes that may be needed or that occurred with the patient.

4. Identify the skilled interventions needed for the patient.

Clinicians should be able to determine what exactly needs to be done based on the care plan.

5. Include patient, caregiver, and family participation.

Care plans should include insightful quality care that is meeting the needs of the patient and family.

How does MatrixCare support a well-written care plan?

MatrixCare offers a robust library of interventions and goals, as well as the ability to create agency-defined care plans.

Clinicians document in the patient care plan based on their assessment. If the clinician documents in the visit note something that is not part of the care plan, MatrixCare will make suggestions for new interventions.

More benefits of a MatrixCare-supported care plan include:

• Historical information at your fingertips
• Designed to help meet regulatory requirements
• Speech-enabled documentation at the point of care
• Secure, real-time messaging with care teams, partners, patients, and family caregivers
• Ready access to nationwide networks allowing bi-directional clinical information