“Every picture tells a story, don’t it?” Rod Stewart sang to us in an old ’80s song based on a popular British idiom.
These days, a home health patient’s records need to tell a story, too — and it had better be a thorough one, reflecting a coordinated care plan and continuity of care, with realistic goals and outcomes, or the agency could risk costly claims denials.
Under this month’s new Medicare and Medicaid regulations, home health agencies are responsible for much more detailed documentation throughout the home care delivery episode than ever before.
“Now that we’ve transitioned into IC-D10 coding, you really have to be much more specific,” says Holly Kolitz, Quality Assurance Manager for Home Health Solutions LLC. “Basically, you’re creating a little window of what happened while you were there.”
Holly and other HHS team members work with agencies of all sizes across the country to streamline operations, helping health care workers adapt to new regulatory requirements and avoid costly claims denials.
As part of that process, they train health care professionals in the mechanics of specificity: how to sift through the agency’s many, many interactions with and on behalf of a patient to glean the specific details which must be documented.
It’s a balance
Turns out there’s something of an art to capturing the nitty-gritty of patient care, especially in the notes recorded in the field by nurses and clinicians.
Too many useless details serve no real purpose, frustrating the peers, supervisors and auditors who review them. But too few details can create dreaded “black holes” of home health documentation, where failing to record what was said or done, and show cause for it, can wind up costing an agency thousands of dollars.
Finding the right balance between those two extremes is proving to be at least somewhat intimidating to most agencies. Their nurses and clinicians generally aren’t storytellers, scribes or court reporters; they’re caregivers.
And very busy caregivers, too.
“Today’s home health field is fast-paced,” Holly says. “A lot of expectations are placed on caregivers, and each home visit has to be a well-rounded visit. But proper documentation has become an imperative part of the process.”
How can caregivers identify and learn the pertinent details which must be included in their notes?
The 5 Ws
The Home Health Solutions team often starts its specificity training with a review of one of the oldest, simplest and most reliable formats for capturing information: a basic list known as “The 5 Ws.”
Five words beginning with W — Who, What, When, Where and Why — will capture almost every detail caregivers need to include in their files. A sixth word — How — adds more important information.
Simple? Yes, but many agencies struggle with reporting each of those six aspects of information, particularly with recording WHY something is being done, and later with capturing HOW it was done.
Tell me WHY
Applying the 5Ws begins the moment a patient is referred to the agency, with the WHO and WHEN aspects covered in the on-boarding and intake process.
But the information collection system often breaks down immediately afterward, as agencies fail to record WHY they are providing services to the patient in the first place.
Failure to include documentation showing medical necessity for home health services, including the initial referral by a physician, is the No. 1 documentation error most agencies make, according to Heather Calhoun, Director of Special Appeals and Project Management at Home Health Solutions.
Care goals and 5 Ws
As managers develop comprehensive care plans for patients, coordinating services between various types of caregivers and establishing realistic goals, application of the 5 Ws can once again make significant contributions to the quality of the patient file.
In developing the comprehensive plan, be sure to include WHY and HOW each service will be provided, with specific documentation showing its medical necessity.
In the field
The 5 WS must be captured in the field, too, as caregivers actually deliver the planned treatment and services, and record doing so.
Notes should reflect not only WHO delivered each treatment or service, WHERE and WHEN, but continue to refer to WHY. Ideally, the WHY portion of the clinician’s notes will refer to the comprehensive care goals set for the patient, as well as addressing any specific goals for that particular visit.
Finally, caregivers must record WHAT they do and HOW.
It isn’t enough, for example, for a caregiver to note that she taught her patient the purpose of a particular pill and its side effects. Quality notes will reflect why she reviewed this information with the patient, what information she shared and even how the patient reacted.
“The nurse would need to summarize in a paragraph what she told the patient to educate the patient on the importance of the medication and encourage the patient to be compliant in taking it,” Heather says.
New documentation standards may seem overwhelming to agencies, but the Home Health Solutions team is encouraging. Much of the attention to detail now required of caregivers hearkens back to quality practices drilled into nursing school students, they say, and will become second nature with practice.
If your agency needs staff training to better meet new regulations, Home Health Solutions offers a comprehensive array of customized modules and on-site services.
THURSDAY: Tying up all the loose ends in your agency’s paperwork