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Working Through The Care Plan: Drill Down To Why You Aren’t Getting The Outcomes Financially Or Clinically You Desire. Then, Make It Rain!

game changer photo

Today, your EMR care plan isn’t necessarily a true depiction of what you want to accomplish in the home. Home health agencies realize that goals aren’t met unless ALL the goals are met. Unfortunately, because the construction of the care plan is often unrealistic, then meeting all goals is a problem too. If you are one of those agencies, then it is time for change. Let’s look at how to make care plans realistic and how to road map the path to completing the goals.

SWOT your process:

Taking a hard look at your current process is tough. The idea of changing processes can feel overwhelming.  If you do not approach it with a plan, then it absolutely will be. Start with a true SWOT analysis of what works and what doesn’t. Really analyze why clinicians choose certain interventions versus others. Consider how many interventions a clinician feels MUST be there in order to justify a 60 day certification period.  This may sound like a strange sentence to consider, but it isn’t. Most clinical people write a care plan with frequencies to last through the entire cert even when discharge would be anticipated sooner.  There are often clinical pathways in the typical EMR that lead to interventions in the dozens. Here are some items to consider:

  • How Many Interventions Does Your 485 Have On Average?
  • Do Clinical Pathways Add Interventions That Could Be Irrelevant?
  • What Process Is Used By Clinical Staff To Address Care Plan Items?
  • Does Record Review Reveal Consistent EMR Interventions Not Addressed?
  • Do Clinicians Check The Care Plan Prior To The DC Summary/ Order?
  • In Completing The SWOT, Are The Care Plans Realistic?
  • Who Reviews The Care Plans After Admission? Are Changes Made?

Putting The SWOT Findings Into The New Care Plan:

The bottom line is to make your care plans lean. Meaning, they should be focused on what the central issue to health and wellness is for the patient. There is no point to an extra 30 interventions that can never be addressed in a meaningful way. A system needs to be in place that addresses the outcomes and progression of goals in each visit and what the game plan is for the next visit. There should be no overlap or “visit wasted” that doesn’t relate in a meaningful way back to accomplishment of discharge goals.

You need the gatekeeper in play here. Enter the clinical manager or assigned case management team. Managing the care plan can’t exist with one person. It must be collective. The clinicians need to communicate in each visit how what they did progressed a patient to the goal. The therapist has been reporting to you the repetition of exercises done through that week. Great, but that doesn’t tell you if the patient can now safely transfer in and out of the shower with assistance so the aide care plan can change. It doesn’t have anyone working directly with the aide through a progression that includes the termination of aide services before the discharge from the agency’s care. We still have everyone doing their own thing and randomly giving the clinical managers a discharge date. Guaranteed, there will be visits wasted in this scenario. With a laser-focused clinical manager, all the moving parts of the care plan can function in tandem with better outcomes and less overall cost to the agency providing care.

Changing Your Process Takes A Strategic Plan:

At Kenyon Homecare Consulting, we focus on high-quality care in the home and helping agencies to get there. If you wish to change the clinical process in your agency to achieve better clinical and financial outcomes, please call us at 206-721-5091 or contact us online for your free 30 minute consultation with a senior consultant.

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