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Reading the Tea Leaves – Home Health at a Critical Juncture! [2HR]
Reading the Tea Leaves – Home Health at a Critical Juncture! [2HR]
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CodeProU: Home Health Essentials

[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

Education-Training Credits:

    • 1.0 Contact Hr, Continuing Education for Nurses (Awarded per Program)
    • 5.0 Contact Hrs, Continuing Education for Nurses (Total Available & Awarded Upon Completion of all Five Programs)

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 [5] one-hour programs. A brief program description, topics addressed and learning objectives are shown below for each program in this series.

Program One [1] 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.

  • Topics Addressed:
    • Medicare Requirements for the Home Health Benefit
    • Homebound Definition & Homebound Status
    • Skilled Care Requirement
    • Resonable & Necessary Requirement
    • Skilled Care: Interventions, Goals, Documentation
    • Physician Orders, Therapy Visit Notes, Under Care of a Physician
    • Plan of Care [POC]
      • Content
      • Initial Certification POC
      • Recertification POC
      • Certification for Management & Evaluation
      • Coordination of Care
    • Face-to-Face
    • Recert or Discharge? Coverage Criteria & Care Coordination
    • Medical Review: Top Denials
  • Learning Objectives:
    • State Medicare coverage criteria for Home Health benefit
    • Discuss strategies to validate homebound, medical necessity and skilled intermittent care
    • Identify documentation points to support Medicare coverage requirements
    • Discuss considerations to decide “recert or discharge?”

Program Two [2] 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.

  • Topics Addressed:
    • 2018 Conditions of Participation - Care Planning, Coordination of Services & Quality of Care § 484.60
    • Shared Decision-Making Model
      • Individualized POC
      • Patient Participation
      • Physician Coordination
    • Components of POC
    • Hospitalization Risk Assessment and POC
    • Strategies for Care Planning
      • Comprehensive Assesment
      • Goal Setting
      • Measurable Outcomes
      • Interventions
    • Documentation Points
      • MAC Red Flags
      • Care Planning
      • Education & Training
  • Learning Objectives:
    • State Conditions of Participation requirements for patient involvement in care planning (2018)
    • Discuss strategies to include patients and families in care planning, goal setting and discharge planning
    • Identify two key components of documentation to support care planning with patients, families and caregivers

Program Three [3] 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.

  • Topics Addressed:
    • 2018 Conditions of Participation - Care Planning, Coordination of Services and Quality of Care § 484.60
    • Shared Decision-Making Model
      • Coordination of Care
      • Physician Coordination
      • Interdisciplinary Teams
      • Integration of Orders
      • New Standard § 484.110
      • Documentation
    • Strategies for Care Coordination
      • Coordination of Care - Physician Coordination, Interdisciplinary Coordination, Who Does What
      • Conference Points - SOC, ROC, Recertification, Discharge of Discipline, Discharge
      • Family/Patient Coordination
      • Patient Performance
      • Caregiver Assistance
      • Education and Training
      • Coordination to Reduce ACH
    • Documentation Points
      • Care Coordination
      • Interdisciplinary Coordination
      • Discharge/Transfer Summary
  • Learning Objectives:
    • Define care coordination
    • State 2018 Conditions of Participation for care coordination
    • Identify care coordination key information at comprehensive assessment time points
    • Relate care coordination to goal achievement and reducing acute hospitalizations

Program Four [4] 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.

  • Topics Addressed:
    • Regulations Governing Home Health
      • Compliance
      • Conditions of Participation
    • The Survey Process
      • Goals of the Survey Process
      • Survey Types
      • Top Complaint Allegations
      • Classification of Survey Deficiencies
      • Survey Activities
        • What the Survey Looks For
        • Survey Interviews
          • Questions for Clinical Managers
          • Questions for Clinical Staff
        • Survey Record Review
        • Home Visit Key Points
        • Survey Interviews
          • Questions for Patients & Caregivers
        • Common Citations
        • Clinician Actions: What Needs to be Done
          • Clinician Documentation
          • Key Points for Clinicians
          • Managers Role
          • Key Points for Managers
      • Immediate Jeopardy
        • Definition & Considerations
        • IJ Timeline
        • How to Avoid an IJ and Pass Your Survey!
  • Learning Objectives:
    • State three home health regulations in the 2018 Conditions of Participation
    • Identify key points of the home health survey process
    • Discuss strategies to promote compliance with CoP regulations for successful survey
    • State two actions clinicians can do to demonstrate compliance

Program Five [5] 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.

  • Topics Addressed:
    • Every Patient is the "Ideal" Patient...Not!
    • Demonstrate Professionalism
      • At Start of Care
      • During Routine Visits
      • At Discharge
      • Challenges
      • Setting Expectations
    • Noncompliance with POC
      • Understanding of Condition
      • Knowledge of Management
      • Resources and Support
      • Commitment to Wellnes
      • Using Patient Contracts
    • True Noncompliance
      • Strategies for Noncompliance
      • Willful Failure to follow POC
      • Lack of Progress
    • Discharge
      • Discharge Disagreement
      • Discharge for Cause
      • Surveyor Considerations
      • Surveyor Point of View
    • Use the Four "R's"
  • Learning Objectives:
    • Discuss challenging patient/family situations common to home health
    • Identify strategies to address “non-compliant” patients
    • Explain use of patient contracts to enhance goal-oriented care
    • State two strategies at initial visit to promote a healthy agency-patient relationship

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:

  • The Agency Subscription Fee is per-CMS Certification Number (CCN)
    • Agency Subscriptions permit access for multiple clinicians
    • Does your organization have multiple CCNs? Contact HCIN directly for discounted fees applicable to your organization.
  • Three [3] Month Access Period: $495.00
  • Six [6] Month Access Period: $695.00
  • Twelve [12] Month Access Period: $895.00

Individual Subscription Fee:

  • Individual Subscription - Two [2] Week Access Period: $149.00

All Agency & Individual Subscriptions Provide:

  • access to the registered user
  • access to the rich-media training 24/7 from home and office
  • access and viewing an unlimited number of times during the subscription period
  • upon successful completion, nurse CE for each registered individual

Ordering Information:

  • Single CCN Agency and Individual Subscription orders can be placed online through this store. To order, select subscription type and duration, add to shopping cart and checkout. You may also order by phone. Contact HCIN if you have any questions!
  • Multiple CCN Agency Subscription orders - please contact HCIN directly for your discounted fee and to order.

[CPU5630] CodeProU: Home Health Essentials for Clinicians

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This product was added to our catalog on Wednesday 04 October, 2017.

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