[CPU5630] CodeProU: Home Health Essentials
An essential 5-program series for Clinicians, Clinical Managers, and Quality Improvement Staff
Faculty: Teresa Northcutt, BSN, RN, COS-C, HCS-D
Subscription Type: Agency & Individual
All home health clinicians need a basic understanding of the Conditions of Participation, but care delivery must go beyond the basics!
This series provides five hours that focus on the essentials that field staff and managers need to learn, understand and apply to ensure survey compliance, improve quality outcomes
and increase patient satisfaction. The series addresses Medicare coverage criteria, the new 2018 CoP’s for care planning and care coordination, the survey process and requirements
to meet regulatory compliance, and strategies to set boundaries to promote a healthy agency-patient relationship. This series can serve as an introduction to home health for new
clinicians, and as a refresher on the regulatory compliance requirements for those who have been working in home care and need to stay up to date with the new CoP’s.
Home Health Essentials is comprised of five  one-hour programs. A brief
program description, topics addressed and learning objectives are shown below for each program in this series.
Program One  Home Health Coverage [1HR]
- Teresa starts with the basics of Medicare coverage criteria for home health patients: homebound status, medical necessity
for skilled intermittent care, under a physician directed Plan of Care, coordination of care, and a brief overview of what clinical
staff need to know about Face-to-Face. She discusses assessment strategies to determine if patients meet coverage criteria and identifies
key documentation points to support these Medicare coverage requirements, reviews the contents of the Plan of Care with new items added in the 2018 CoP’s,
and discusses some examples of home care patients to illustrate the things to consider when deciding whether to recertify or discharge a patient.
Program Two  Care Planning [1HR]
- Teresa outlines the 2018 CoP requirements for patient involvement in care planning and the steps in the care
planning process: assessment to identify patient needs, getting patient and family or caregiver input into goals
setting, determining measurable goals and outcomes, care planning interventions to meet needs and achieve goals
with input from the physician, agency disciplines and the patient/family caregiver. New CoP requirements for
hospitalization risk assessment, training in health management and discharge planning, and patient’s written plan
of care and notification of any changes. This module wraps up with discussion of documentation components to
support the standards for care planning.
Program Three  Care Coordination [1HR]
- In this program, Teresa defines care coordination, reviews the 2018 CoP’s on care coordination
with the patient, family/caregiver/representative, various physicians caring for the patient and all the
disciplines involved in the plan of care. She provides a checklist of key information to coordinate at
each comprehensive assessment time point (SOC, ROC, Recert, Discharge of a discipline, and Discharge from the agency),
gives tips on using care coordination to achieve goals and reduce acute care hospitalizations, and documentation points
to show coordination of care was done effectively and the discharge or transfer summary contains all necessary information.
Program Four  Home Health Regulations & Compliance [1HR]
- Teresa identifies the key points in the Home Health survey process for Level 1, Level 2 and extended surveys to make
sure you are following regulatory guidance as well as meeting payment coverage criteria. She gives examples of common
citations, the questions a surveyor might ask the clinical manager, clinical staff, and patients/caregivers at home visits,
and the documentation that needs to be in the medical record. She discusses actions clinicians can take to demonstrate compliance
with the Drug Regimen Review, aide supervision, care coordination and evaluation of progress toward goals. She also presents
some strategies to promote compliance with the CoP regulations to avoid an Immediate Jeopardy situation and have a successful survey.
Program Five  Boundary Setting [1HR]
- Teresa wraps up this series with a fun yet practical program discussing the challenging patient and
family situations often encountered by home care agencies, and shares some of her own not-so-common
experiences as she struggled with boundary setting as a new home care nurse. She will help you set
realistic expectations at the initial visit and start of care to get the agency – patient relationship
off to a good start, get the most out of routine follow up visits, address non-compliant patients and
caregivers and use patient contracts to enhance goal-directed care, and discuss strategies to prepare the
patient for a successful and mutually agreeable discharge.
About the Presenter: Teresa Northcutt, BSN, RN, COS-C, HCS-D, HCS-H is a Senior Consultant with Selman-Holman & Associates. Theresa previously worked for Primaris,
the Quality Improvement Organization (QIO) for the State of Missouri. She is a dynamic presenter of training for home health agency clinical staff on OASIS assessment
and coding, focusing on customized clinical education programs and the practical application of guidelines by field staff. In addition, she has provided educational
programs on agency communications and processes, quality outcome improvement, and care transitions for regional and state conferences. Certified in OASIS competency
(COS-C), Homecare Coding Specialist-Diagnosis (HCS-D), Homecare Coding Specialist-Hospice (HCS-H) and as an AHIMA Approved ICD-10 Trainer, Teresa brings comprehensive and contemporary knowledge of home care
and quality improvement methods.
Teresa has had experience as Clinical Services and QI/Education manager with home health agencies (independent, hospital-based,
and county health dept.), and as a hospital resource nurse, patient educator, and quality improvement facilitator. She received her BSN from St. Louis University.
Agency Subscription Fee:
Individual Subscription Fee:
All Agency & Individual Subscriptions Provide:
[CPU5630] CodeProU: Home Health Essentials for Clinicians