Is your agency’s care coordination making the grade?

From survey scrutiny to performance scores under Value-Based Purchasing, reasons are mounting for both home health and hospice agencies to structure regular care coordination meetings into the work schedule -- and make certain those interdisciplinary discussions are well documented.

Care coordination, mandated by Medicare’s Condition of Participation, remains one of the most common citation areas on home health surveys, according to the compliance and clinical operations experts at SimiTree.

“While the plan of care is always the No. 1 area for citations, care coordination consistently ranks right up there,” said SimiTree Compliance Senior Manager Sheila Salisbury-Sizemore.

She and other SimiTree consultants are working with agencies to boost care coordination efforts prior to the nationwide expansion of VBP, when the stakes will climb for home health.

“One of the goals of the nationwide rollout of VBP is to integrate and coordinate care,” Salisbury-Sizemore said. “Under the first performance year of VBP in 2023, home health agencies will be scored in part on the patient’s perception of their communication and team discussion.”

Coordination of care to ensure accuracy on OASIS-based measures will also be key under VBP, Salisbury-Sizemore said.

An agency’s total performance score under VBP will be based on claims-based and OASIS-based measures as well as five elements of the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) Survey. Patient perception of communication and team discussion are two of those five elements.

The HHCAHPS Survey will determine 30 percent of an agency’s total performance score, and that score will in turn determine the agency’s payment adjustment for 2025.

“When we see so many home health agencies struggling with poor survey performance in this area right now, we know that they are also going to perform poorly in these areas under VBP,” Salisbury-Sizemore said.

Hospice surveys

Hospices also need to be concerned about care coordination, SimiTree consultants say.

The Centers for Medicare and Medicaid Services (CMS) is ramping up survey scrutiny for hospice this year, training surveyors to focus on interdisciplinary group care planning and coordination of care as part of an emphasis on meeting four core Conditions of Participation.

Other areas of emphasis in basic surveyor training are patient rights, initial and comprehensive assessment of the patient and Quality Assessment and Performance Improvement (QAPI).

“As part of CMS efforts to update basic training for surveyors this year, it included an emphasis on these four areas,” Salisbury-Sizemore said. “It is also providing training to accrediting organization surveyors to carefully review written plans of care.”

A closer look at care coordination

Care coordination occurs when patient information is shared among all participants involved in the care process to better ensure safer and more effective care. In broad terms, it’s care management through team work.

Examples of care coordination may include structured meetings such as routine, formal case conferencing with the patient representative or a regularly scheduled, interdisciplinary team meeting to coordinate care, discuss goals, map out roles and responsibilities and address any barriers that may be preventing the patient from receiving services.

But care coordination also includes communication outside regular meetings. For example, it may include communication between the LPN and the RN to promptly discuss any condition changes such as wound deterioration or weight gain, or the report made by the physical therapy or occupational assistant to the clinician in charge.

Surveyors will look for both structured and unstructured types of care coordination, SimiTree consultants say, to assess how well the care team members are communicating and collaborating to provide better patient care.

The medical record should show that the care team adequately assesses and meets patient needs, effectively communicates to each other information about the patient, then monitors, follows up and responds to changes.

“When there is a citation, it usually boils down to somebody not telling somebody something they should have,” Salisbury-Sizemore said. “It’s about closing the loop, and making sure the right information is shared so that the agency can do the right thing for that patient.”

Minimum timepoints for coordination

Since agencies can’t bill for time clinicians spend away from the front line, setting aside dedicated time for regular care coordination may not happen regularly.

“But care coordination needs to be baked into the productivity standard at an agency,” said Laura Wilson, SimiTree Managing Director of Clinical Operations Consulting.

At a minimum, SimiTree consultants say, each patient’s medical record should reflect care team coordination at the following timepoints:

  • Start of care
  • In the final few days of the 30-day billing period, ideally as part of a routine evaluation to determine whether there will be a change in the agency’s focus of care
  • When there is a problem or change in the patient condition
  • In the two weeks leading up to the date of re-certification
  • As part of discharge planning

“These are just the basic timepoints,” Wilson said. “For more complex cases, there should be more frequent coordination.”

Tips for care coordination

SimiTree consultants have a few suggestions to help ensure care coordination is prioritized at agencies.

Schedule regular care coordination meetings. In addition to communicating information about the patient to all parties, a weekly or biweekly meeting can help agencies establish accountability, agree on roles and responsibilities, monitor and follow up on any changes in patient needs or goals, plug the patient into community resources, and help with transitions of care.

Involve all members of the care team. “Back in the day, we used to have Interdisciplinary Team (IDT) meetings and that was always where the magic happened,” Wilson said. “Everyone had input. These days we tend to work in silos, without that interdisciplinary interaction.”

If your agency struggles to find time for interdisciplinary meetings, Wilson recommends virtual meetings. A proponent of the many ways in which telehealth can help an agency accomplish more in less time, she believes virtual meetings are underutilized in an era of staffing shortages and busier workloads.

Salisbury-Sizemore encourages agencies to include home health aides in these meetings. “They’re really the eyes and ears of the patient,” she said.

Document all coordination. At busy agencies, many instances of care coordination occur throughout the day as clinicians go about their jobs – but not all get documented. A phone call to quickly confer with another care team member about the patient, for example, needs to be noted in the medical record.

“The old nursing school adage still applies,” Salisbury-Sizemore said. “If it didn’t get documented, it didn’t get done.”

Make sure the documentation makes it into the medical record. Salisbury-Sizemore, who was an Accreditation Commission for Health Care (ACHC) surveyor prior to joining SimiTree, has a cautionary tale of the agency with notes showing near-perfect care coordination meetings.

“The clinical manager was new, and doing an exemplary job of holding weekly meetings,” Salisbury-Sizemore said. “They discussed their patients, reviewed problems like falls and complaints, and kept detailed notes in a binder for anyone to access at any time. Other than the binder, they were doing everything right.”

But rules are rules, and there was no mention at all of any care coordination in the medical records, technically placing the agency in violation of care coordination requirements.

“So we can’t just say that if it didn’t get documented, it didn’t get done,” Salisbury-Sizemore said. “We have to add that if it didn’t get documented in the medical record, it didn’t get done.”

Share the documentation burden. Busy clinical managers shouldn’t have to bear the documentation burden alone, SimiTree consultants say, especially during a staffing shortage which often makes it hard to field enough staff to see patients. They recommend agencies look for ways to support the clinical manager by delegating some documentation efforts. Operations, schedulers and some back office staff members may be able to step in, taking notes in meetings, following up on equipment tracking, etc.

Focus on follow-up. Smart agencies place a large emphasis on follow-up, having in place a variety of procedures and requirements and holding all their care team members accountable.

“In a hospital setting, clinicians close out their shifts with a report,” Salisbury-Sizemore said. “It’s a little different for home health or hospice, but agencies need to establish the mindset of follow-up. When a patient is referred and has special equipment needs, for example, who is following up to make certain the patient receives that equipment? When the equipment is provided, is it documented in the medical record that the patient received it? Follow-up is always an integral part of care coordination, and something surveyors are going to look at very closely.

“Follow-up is closing the loop,” she said. “Always make sure the loop is closed.”

SimiTree can help

Adopting a strong care coordination mindset has never been more important for both home health and hospice agencies, SimiTree consultants say, and the benefits extend far beyond survey or VBP considerations. Well-designed, targeted care coordination processes improve outcomes for patient, provider, and payer.

The friendly experts at SimiTree can help identify problems at your agency with a thorough operational assessment designed to improve your processes for increased efficiency and determine how effective your care coordination efforts are.

Our consultants can also help ensure your agency is ready for the first performance year of Value-Based Purchasing in 2023.

We’ll also help you identify other survey vulnerabilities and establish an ongoing culture of survey readiness. Our regulatory team is made up of current, former, and certified surveyors who have the industry knowledge and experience to assist both hospice and home health agencies in implementing new and changing regulations and shoring up survey readiness.

SimiTree’s thorough mock surveys are offered on-site or remotely. We identify potential survey citations using the Medicare State Operations Manual (similar to a surveyor), provide extensive survey readiness guidance, and will then work with your organization to develop and implement a corrective work plan to make sustainable improvements.

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