Fans of puzzles know that solving one requires the creation of a particular kind of order, putting the pieces together in a logical way in to arrive at the correct solution.
Home health professionals perform similar tasks daily as they create orderly files made up of many different documents, from an initial referral by a physician to notes made by the nurse seeing a patient in the home. Just as a jigsaw puzzle is made up of interlocking pieces, with each piece depicting a small segment of the whole, the many different pieces of documentation that go into a patient’s file work together to create the larger picture of the patient’s health care experience with the agency.
And under new Centers for Medicare and Medicaid regulations that took effect this month, there can’t be any gaps in that picture.
A cohesive whole
One of the best, and simplest, ways for agencies to ensure that each step of the documentation process integrates seamlessly with all other pieces is to ask why an action is being taken or a procedure is being performed, according to J’non Griffin, owner of Home Health Solutions LLC.
Why was the care referenced in the documentation delivered? Was it medically necessary? Then agencies must show proof of that necessity.
Why was each visit made? Was it was part of the agency’s overall plan of care for the patient? Then visit notes should say so.
Approaching each piece of documentation with a goal of answering “why” will help knit together an interlocking summary of patient care and identify missing pieces that are likely to lead to costly claims denials.
Do all the pieces work in tandem?
Documentation must support the visit type and the visit type must support the plan of care. Notes made by clinicians in the home must clearly justify the visit and show the value as it relates to goals established in the plan of care.
“Quality documentation begins at the time of the patient’s initial referral to home health by a physician, and continues through each aspect of home care,” J’non says. “If each step is properly documented, the result will provide a comprehensive and cohesive file that will stand up to scrutiny.”
J’non and her team work with agencies of all sizes across the country to streamline operations, teaching agencies how to minimize compliance risk, untangle and make sense of regulatory changes and maintain quality patient care.
Keep things realistic
Once OASIS data has been carefully collected and properly recorded, a case manager must evaluate and make use of that data to develop a realistic plan of care for a patient based on the assessment.
Clinical notes made in the field will then need to integrate seamlessly with that plan of care, not only fully supporting the visit type and acknowledging goals, but also measuring progress.
Notes will need to show clearly how the care plan is being executed with purpose at each visit.
Billing must be part of an agency’s comprehensive documentation as well. In addition to supporting all others, each piece of documentation in a file must support all related bills and claims.
Home Health Solutions team members understand the challenges facing home health care professionals as they try to adapt to the many regulatory changes implemented this month.
But implementation of the four strategies outlined in this week’s series of blog posts can make noticeable improvements in an agency’s compliance efforts and ensure that documentation will stand up to scrutiny in 2016.
“And if additional assistance is needed, we can provide the training and guidance needed to help agencies stay on track and focus on quality patient care this year,” J’non says.