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Why Care Coordination Is Important for Home Health and Hospice Agencies

A well-designed care coordination process benefits patients, providers, and payer organizations. Improved care quality and patient safety, reduced readmissions and ER visits, and lower healthcare costs are just some of the positive outcomes of effective care coordination.

Though the benefits are clear, many home health and hospice agencies struggle to optimize coordination.

Mandated by Medicare’s Conditions of Participation, care coordination is one of the most common citation areas on home health surveys. “While the plan of care is always the number one area for citations, care coordination consistently ranks right up there,” said SimiTree Compliance Senior Manager Sheila Salisbury-Sizemore.

Care coordination under HHVBP

Salisbury-Sizemore and her colleagues are working with agencies to boost care coordination efforts prior to the upcoming nationwide expansion of the Home Health Value-Based Purchasing (HHVBP) program, when the stakes will be higher 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.” She said that coordinating care to ensure alignment with Outcome and Assessment Information Set (OASIS) measures will also be key under HHVBP.

An agency’s total performance score under HHVBP 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% 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 HHVBP,” Salisbury-Sizemore said.

Comprehensive education for home health staff is vital to boost performance under HHVBP, observed Relias Director of Post-Acute Care Solutions Trish Richardson, MSN, BSBA, RN, NE-BC, CMSRN.

Increased scrutiny in hospices

Hospices should also be concerned about care coordination. 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.”

Assessing communication and collaboration

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

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 preventing the patient from receiving services.

But care coordination also includes communication outside regular meetings. For example, it may include communication between the licensed practical nurse and the registered nurse to promptly discuss any condition changes such as wound deterioration or weight gain. It could also include a report made by the physical therapist or occupational assistant to the clinician in charge.

Surveyors will look for structured and unstructured types of care coordination to assess how well the care team members communicate and collaborate to provide better patient care.

Agencies should be prepared for a surveyor’s constructive scrutiny. “This is the year of compliance with promised increased oversight of care quality and environment of care,” Richardson noted.

Documentation in the medical record

The medical record should show that the care team adequately assesses and meets patient needs, effectively communicates 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.”

Since agencies can’t bill for time that clinicians spend away from the front line, setting aside dedicated periods of 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, each patient’s medical record should reflect care team coordination at the following time points:

  • 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’s condition
  • In the two weeks leading up to the date of recertification
  • As part of discharge planning

“For more complex cases, there should be more frequent coordination,” Wilson said.

Strategies to improve care coordination

Below are a few suggestions to help you prioritize care coordination.

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, connect the patient with 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 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. Virtual meetings are helpful amid 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 surveyor prior to joining SimiTree, has a cautionary tale of an agency with notes showing near-perfect care coordination meetings. “The clinical manager was new and doing an exemplary job of holding weekly meetings,” she 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 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 can’t bear the documentation burden alone.  SimiTree recommends that agencies support clinical managers by delegating some documentation efforts. Operations, schedulers, and some back-office staff members may be able to step in to take notes in meetings, follow up on equipment tracking, and more.

Focus on follow-ups. Smart agencies place a strong emphasis on follow-up, supported by procedures, requirements, and accountability.

Although home health and hospice nurses don’t close out their shifts with a report as in hospitals, they can establish a similar mind-set of follow-up. Salisbury-Sizemore provided an example: “When a patient is referred and has special equipment needs…who is following up to make certain the patient receives that equipment? When the equipment is provided, is it documented in the medical record?” she asked.

“Follow-up is always an integral part of care coordination, and something surveyors are going to look at very closely,” Salisbury-Sizemore said. “Always make sure the loop is closed.”

Note: This content was adapted from a blog originally posted by our partner SimiTree.


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