TIP OF THE WEEK
An Interdisciplinary Team Approach to Transitional Care
Transitioning a patient through various healthcare settings often requires an interdisciplinary team approach. Every member of the team has an area of expertise that can educate the patient on ways to improve self-management as well as help the team recognize important information that will be needed by providers in other levels of care. The following discusses the role of several key team members:
INTAKE COORDINATOR
The most effective planning for a patient may occur at the time the patient is accepted for care by the healthcare provider. In the home health agency, it’s most helpful to get information not just about the patient’s medical conditions and treatments, but also as much information about the support system he or she will have at home.
“The responsibility of the hospital medical social worker/discharge planner is to ensure a positive and appropriate discharge for every patient; the responsibility of the home health agency is to foster effective communication with the hospital social worker/discharge planner to ensure that a positive/appropriate patient discharge occurs.” [1]
NURSING AND HOME HEALTH AIDES
The nurse coordinating the patient’s care and education is best equipped to note patient and caregiver health literacy. Make sure the primary caregiver is correctly identified: educate the person who may be living in the home with the patient as well as the person who appears to make most of the decisions about care, if the two are different. Home health aides may see the patient’s true functional level more often than other members of the home health team; they should be aware of the plan of care and how their observations can assist in making sure that the patient is appropriately monitored and educated.
THERAPISTS
Communicate the current therapy plan of care with other members of the home care team. Be aware of medical conditions and medications that may interfere with progress with therapy or increase risk for falling. Communicate when a patient reaches a plateau or backslides with therapy, as this may be an early signal of declining health status.
SOCIAL WORKER
Sometimes the reason for patient non-adherence is related to financial or other matters. Lack of support for a sole caregiver may result in avoidable hospitalization to provide respite care. Other factors that may result in care transition include lack of financial means to obtain medications, monitoring devices such as a blood pressure cuff or scale, or appropriate nutrition.
“Be aware of factors that may affect the patient taking his or her medications correctly.” [2]
Every person coming into contact with the patient should have the ability to add insight into the patient’s care as well as response to care. By tracking as much of that information in the home health record as possible, the agency can help ensure that pertinent information is transitioned to the next healthcare provider, which may prevent unnecessary care down the road.
RESOURCE SPOTLIGHT
Cardiac Care Concerns Teleconference Recording Available on CD-ROM
Date recorded: March 6, 2008
Speaker: Kathy Machingo, RN, BSN, CNA-BC, Manager of the CHG Clinics for St. Joseph and St. Elizabeth Health Centers
Learning Objectives:
- Describe the pathophysiology of heart failure.
- Develop a plan of care that includes preventable measures for heart failure.
- Describe the reportable symptoms and early interventions for worsening heart failure.
- Describe clinical implications of core medications for heart failure treatment.
Click here to order today
(Allow 10 business days for delivery)
IN THE NEWS
March 28, 2008 -- CMS -- The Centers for Medicare & Medicaid Services (CMS) released a final notice announces our decision to approve the Community Health Accreditation Program (CHAP) for recognition as a national accreditation program for home health agencies (HHAs) seeking to participate in the Medicare or Medicaid programs, effective March 31, 2008 through March 31, 2012. Read more >>
APPROVAL OF THE JOINT COMMISSION FOR CONTINUED DEEMING AUTHORITY FOR HOME HEALTH AGENCIES
March 28, 2008 -- CMS -- The Centers for Medicare & Medicaid Services (CMS) released a final notice announces our decision to approve The Joint Commission for recognition as a national accreditation program for home health agencies (HHAs) seeking to participate in the Medicare or Medicaid programs. Read more >>
THE NPI WILL BE REQUIRED FOR ALL HIPAA STANDARD TRANSACTIONS ON MAY 23RD
March 20, 2008 -- MCS -- Now that the National Provider Identifier (NPI) is required on all Medicare claims in the primary provider fields, if your claims are being successfully processed with NPI/legacy pairs (and most are) now is the time to begin testing claims using the NPI alone.
More Information | Apply for NPI Number
COMING ATTRACTIONS
Ohio Council for Home Care – Upcoming Education
- April 11th – Hospice 101
- April 15th-16th – OASIS Revisited
- May 13th-15th – Breaking the Code – Competency in Diagnostic Coding
Ohio Hospice and Palliative Care – Upcoming Education
- April 8th – Basic ICD-9 CM Coding Class
- April 9th – Beyond Basics ICD-9 CM Coding Class
- May 12th – Palmetto GBA Updates for Hospice and Home Care
Health Policy Institute of Ohio: Regional Meetings on the Ohio Family Violence Prevention Project
- April 4th in Youngstown
- April 11th in Cleveland
- May 2nd in Toledo
- May 9th in Lima
- May 16th in Cincinnati
- May 23rd in Zanesville
The Tip of the Week Archive is available on the Ohio KePRO Web Site.
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