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What is a care plan in home health and hospice?

Most people associated with home health and hospice are familiar with the term plan of care. Referred to as the generic plan of care in hospice and the CMS-485 document in home health, a care plan is just one component of that overarching plan of care — a critical component to both home health and hospice due to the high rate of deficiencies associated with care planning.

Surveyors focus on the care plan because it’s critical to the care of the patient.

The care plan encompasses several things. It puts a plan in place for frequency of visits to the patient’s home, when visits will take place, what will be accomplished during the visit, and what outcomes need to be achieved during that episode of care. The plan of care defines the care plan goals and the interventions required to reach those goals. It needs to be clear, concise and the goals must be measurable — whether it’s creating comfort for hospice patients or allowing home health patients to achieve maximum potential.

With hospice and home health having two different end games, how is a care plan developed?

The referral

A care plan begins with the referral. When we obtain a referral, we’re provided physician orders regarding the patient needs. When we visit the home, assess the patient, and meet with the family or caregiver, we must be modifying the care plan based on our clinical assessment.

Start of care visit

From the minute we get out of the car and walk up to the patient’s home, we’re gathering information. What kind of environment is it? Did they answer the door? Do they have somebody helping them with their care currently? It’s important to be a detective of sorts and ask the patient to walk you through a typical 24-hour day to get a good sense of what’s going on in the home at different time points — i.e., mealtime, bathing, medication administration, ADL/IADLS etc. For hospice, this walk through a typical day may include asking whether this patient have someone in the home to assist 24/7 or are there gaps of time where they are alone, how is that caregiver feeling, are they overwhelmed? If the patient is on pain meds, can they ambulate safely? What equipment would provide a safer environment?

Standardized Data Sets are collected during the home health (OASIS) and hospice (HIS) during the initial start of care assessment visit. Those questions in the data sets are designed specifically to identify the current condition of the patient at the time of collection. For home health, as care progresses, we take another data set at recertification, discharge or transfer. For hospice the date is collected again at the time of revoking the benefit or death. These data sets are extremely helpful in the creation of the care plan. The MyScrubber feature assists home health agencies in tracking improvements and/or declines functional items on the OASIS while highlighting areas that affect Home Health Compare (HHC), value-based purchasing (VBP) and star ratings.

The comprehensive nursing assessment completed upon admission is critical because we are not able to develop an accurate and effective care plan for the patient until we get a clear picture of their current condition and needs essential to building the care plan.

With MatrixCare, begin with the end in mind.

Clinicians should always be thinking, what is the outcome for this episode of care? What are the measurable goals? What is the patient’s expectation from this episode of care? MatrixCare assists clinicians through use of the physician orders and what is determined on that initial assessment, to create specific interventions and goals that can be individualized to each patient.

The MatrixCare platform begins the care plan process at the start of care visit. One of the many features available to assist nurses in building the care plan is the assessment-based care planning tool. In addition, clinicians may create new care plan components which they can fully customize, or they can choose from the extensive care plan library and make interventions, goals, and outcomes specific to the patient. MatrixCare also allows for the development of agency-defined care plans.

The comprehensive assessment, OASIS or HIS data will help to gather information and assess the patient status and living situation. As the care journey continues, the care plan will be accessible in all future visits with many of the care plan interventions linked to the specific assessment areas within the visit note; this streamlines the documentation for staff and ensures our visits are focused on that specific patient care plan.

MatrixCare helps clinicians create and manage care plans in three key ways:

  1. Library of care plan interventions and goals
  2. Assessment-driven care plan problems/intervention suggestions
  3. Agency-defined care plans or standard orders

The system

The use of built-in tools and system flags/alerts will help identify potential survey deficiencies for the clinician to reevaluate and correct before visit notes are closed. It’s just one way MatrixCare gets on the front end of compliance — helping to prevent deficiencies before they happen.

Request a demo to experience MatrixCare’s many features that simplify care plans and set providers up for survey success.

Mona Landra, BSN

With over 40 years of experience in healthcare, Mona Landry has learned the industry from the ground up — from field nursing to administration. Mona, BSN and Senior Clinical Solution Consultant with MatrixCare Home Health and Hospice, has been with MatrixCare for 13 years, where she began in the implementation division and then moved to her current role. As a former customer, she has seen the transition of the product and the advancement ResMed has brought to the industry — and she can’t wait to help others experience the true benefits of MatrixCare.

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