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Care Planning Under PDGM: Why Getting It Wrong Is Not An Option If You Want To Succeed!

care planning

It is a brand new year in home health.  We are on our second day of PDGM and you have probably admitted new patients. So, what is different about your care planning process today versus two days ago? If care planning process has evolved in the last couple of years to prepare for changes, then great. If you consider PDGM mainly about billing, then you may be in some trouble. Let’s look at why your care plan has to be direct and focused with patient-oriented goals.

Every Visit Must Have A Plan:

Too many care plans today have each discipline functioning independently.  The home health aides get their care plan from the nurse and go give baths. If you think your agency doesn’t function that way, ask some home health aides to define their job role. If you hear, “to give baths” then you have some work to do. Do your therapists get a diagnosis and then do their own care plan for 3-4 weeks? Basically, you hear from them with the discharge date and a report of all goals met? Can the nurse case managers tell you what each discipline is doing for planned visits this week?

Most of the time, we don’t see a truly coordinated care plan. Report is often times generic and not patient specific. We realize over time that sometimes words like patient-centered or patient specific care planning turns into more of a buzz word as opposed to a meaningful guide to caring for the patient. We challenge you to look at a shared care plan approach to coordination of care. This requires clinicians to focus on what each discipline does during hands on care and not just about the number of visits.

Shared Care Planning:

In the world of home health, as in most of healthcare settings, disciplines do not function within the full scope of practice. Full scope of practice means therapists complete basic wound care and medication teaching where applicable. Home health aides complete rehab tasks as directed and instructed by the therapists. It means nurses address rehab and personal care goals during visits as well.

How common is it to see care plans with nursing, OT, PT, and and aide, but the aide completes nothing related to a home exercise program?  Meanwhile, the patient has been on service and is given ambulation goals daily. Is the aide completing these with the patient? Often times, the aide has never been instructed to do so.  The reality is that we all tend to function within what we have defined as our own swim lane. However, our swim lanes should all overlap because scope of practice allows it to happen. Patient care needs to look more like a relay than everyone working side-by-side on different things.

How Do We Change The Definition Of Swim Lanes:

It begins with education. You will hear that therapists aren’t comfortable with wound care or medications. It is a process. Provide the education to improve comfort levels. If it is a wound care patient, then have the nurse complete a joint visit to make sure the therapist is comfortable and able. If there are medication issues, the nurse need to coordinate directly with the therapist to discuss what needs addressed during the visit. Just because scope of practice allows it doesn’t mean we have the therapist complete it without determining competency.

This would be the same for nursing. Someone who has been a nurse for 30 years in a SNF or in home care isn’t ready to be thrown on a pediatric floor completing acute care. So, understand that the investment in the education in a must. Home health aides are no different. You need to train several sharp home health aides who can participate in shared care planning the way it is intended.

Let Kenyon Home Care Consulting Help With The Transition:

Because PDGM requires billing every 30 days, your time lines become even more important with patients. It is a process to change the paradigm of how you provide care. So, don’t expect it to happen overnight or without guidance. Just telling your clinicians to do it without a guide to transition won’t work. At Kenyon Homecare Consulting, we have the staff and senior consultants to help clinicians understand and complete successful shared care planning. Call us today at 206-721-5091 or contact us online to see how we can help you function effectively and efficiently in a PDGM world. Join us on 1/22/2020 for our webinar on Unified Care Planning In PDGM where we take an in-depth look at the guiding principles of shared care planning.

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