You might have read this headline and wondered why we called coordinated care planning the best kept secret. Most agencies see coordination of care as a requirement and therefore, it is completed like “report” in an acute care facility. We are not acute care so it is no wonder that a typical report is not effective in causing change in outcomes. It also leads to additional visits that are unnecessary. This is ongoing cost for our agencies that we have the ability to change. Let’s look at what coordinated care should look like in your agency.
Coordinated Care Versus Reporting:
Let’s do some comparing and contrasting of these two concepts to see what is happening within your home health:
- Reporting: The process is most commonly one clinician regurgitating data to another. If you are the one that receives the report, then you likely hear things like vitals, how many repetitions of an exercise regimen were completed, and if a specific clinical task was completed such as a dressing or IV. You then document these exact things in your coordination of care note. Meanwhile, this is repeated for every patient seen over the course of each day or that week. The process is most generally just what we said, a regurgitation of information. It is all information that can be reviewed by the clinical manager in the visit record.
- Coordination of Care: The process is guided by the care plan. The care plan is written in a way the develops goals to be addressed by all members of the care team. It is not specific to one discipline for the majority of goals. The care plan is altered and updated according to the information provided by the care team. Each team members speaks to how the care completed during each visit specifically advances the goals on the care plan. It is not a “listing” of what was done. It is the physical therapist speaking to the clinical manager about changes to what the aide should be doing within visits to advance “Goal A”. It is the nurse asking the therapist what to complete or assess specific to rehabilitation efforts during nursing visits. It wastes no visit potential. It is the aide speaking specifically to how the patient was able to complete certain functions in accordance with what the goals were for that week. This also includes how the caregivers in the home are being utilized to advance the care plan as well. The clinical manager then documents this progression and game plan for the next round of clinician visits as opposed to just a listing of what is already in the visit note. It is critically putting together your clinical resources to maximize the use of their time with the patient.
How Does This Save You Money?
When you read this, you may think that the process will take more time. Yes, it does. However, when you consider the cost of one visit, regardless the discipline, you still save money. No longer will you have 3 extra physical therapy visits per episode because your nurses and aides work to the maximum potential of their scope of practice assist with rehab goals. Nurses won’t make extra visits that can be completed by the therapist. A simple wound care dressing and basic med teaching doesn’t require additional nursing visits. Work your therapists into simple med reconciliation and wound care. It is done every day with patient caregivers, so why do we shy away from it with clinically skilled people?
Kenyon Homecare Consulting Can Help:
Have you tried to implement coordinated care planning unsuccessfully? Do you want to unify care planning and haven’t been able to make it happen? Kenyon Homecare Consulting can help make it a reality. Join us on February 3rd at 10am PST for our free webinar, Unified Care Planning Should Be Your Best Friend in 2021. Register today!