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Developing an Interdisciplinary, Individualized Plan of Care in Home Health Care

According to recent statistics, home health referrals after acute care hospitalization have exploded, growing 65% to 3.7 million in slightly more than a decade (Jones, Bowles, Richard, Boxer, & Masoudi, 2017).

Individualized patient care planning has always been the cornerstone of efficient and effective care delivery in home healthcare, and this focus is now considered a non-negotiable part of the conditions for participation (CoPs) in Medicare and Medicaid.

A focus on individualized care planning plays an important role in the attainment of strong clinical and financial outcomes for patients and home health agencies.

As the home health segment of healthcare grows due to an aging population, it is necessary to adequately and effectively meet the disease management needs of the population that you serve.

Everyone should understand certain key elements when developing appropriate interdisciplinary, individualized plans of care, as well as the ongoing management of that care.

According to Omdahl in Module one: The care planning process (2006), some of these elements should include information about the patient’s health, while keeping a focus on action the team needs to take to:

  • Identify the patient’s needs.
  • Address and organize problems.
  • Evaluate the patient’s response and progress.

Addressing these key elements ensures that patients receive individualized care that meets their specific needs and promotes positive outcomes.

The Importance of a Plan of Care

Care planning is an important aspect in patient care as it provides an organized structure for identifying patient needs through a comprehensive assessment and for individualizing care to address these needs.

When developed thoughtfully, a care plan ensures consistent, continuous quality care that is efficient and effective through collaboration between healthcare disciplines.

Additionally, an individualized plan of care based upon the patient’s needs usually results in positive outcomes.

Ongoing review of the patient’s progress towards goals allows for the ability to make changes to the plan of care (POC) when it is determined that goals are not being met or new problems are identified.

It provides a written document that communicates to all disciplines and can be referred to at any time. Think of the POC as a road map that directs the individualized care that will be provided by your home health agency and its partners.

It is important that every home visit has a distinct purpose in assisting the patient with reaching their goals, and all disciplines are working together as a team to make this happen.

The Right Approach to Care Planning

Successful care planning requires an organized and systematic approach. It includes:

  • A comprehensive clinical assessment
  • The identification of actual and potential problems
  • plan that encompasses the identification of patient-centered goals and appropriate interventions to reach them
  • Implementation of the plan
  • An evaluation to determine if the plan is meeting the established goals

This approach provides the structure for identifying and addressing needs, and individualizing care.

It paves the way for an interdisciplinary and holistic approach; ensures consistent, continuous quality care; and facilitates an ongoing review of progress toward meeting the established goals.

Required Skills and Abilities for Home Health Care Planning

It is important that all clinicians performing a comprehensive assessment are competent to do so. This will assure appropriate data collection and documentation of assessment findings, as well as provide the support for accurate and appropriate problem identification.

Your knowledge, skill, and ability in data collection can also affect the quality and quantity of data that is gathered, as well as the patient’s willingness or ability to provide information. Ask yourself:

  • Have I had the appropriate training to perform comprehensive assessments?
  • Do I understand CMS’s intent of each element in the OASIS data set?
  • Do I feel comfortable with my data collection knowledge and skills?

Data Collection for Assessment

Skilled clinicians begin the comprehensive assessment by collecting and validating data from a myriad of sources. Documentation is then prepared that describes the patient’s status and other pertinent conditions and how these factors impact health management and maintenance.

For Medicare patients, the comprehensive assessment and the Outcome and Assessment Information Set (OASIS) data elements provide the template for a thorough and complete assessment. Both subjective and objective findings are incorporated into the comprehensive assessment.

The comprehensive assessment findings, along with these OASIS data elements, are to be addressed and documented on the appropriate assessment document. To support the subsequent plan of care, it is essential that all findings outside of normal limits are thoroughly addressed.

This documentation will support the reasons for the care that is provided. An auditor should never read a record and wonder why certain interventions were performed!

At the comprehensive assessment visit, you should validate and confirm the information provided from the referral source and identify the relevance and pertinence to the home health plan of care.

Information from the referral source during the assessment can greatly assist you in data collection and provides an opportunity to identify and investigate other health issues that the patient may experience or is experiencing.

Remember that home health data collection of the comprehensive assessment includes the patient and the environment in which they live.

For example, it’s not enough to acknowledge the existence of a Stage 4 pressure injury but ignore the fact that the individual lives alone in an environment that is unsanitary and puts them at high risk for wound infection.

Subjective information is obtained through interviews with the patient, family, or caregivers. Consultation with other healthcare providers also provides insights into the needs and challenges facing the patient.

Specific psychosocial assessments may need to be performed to evaluate psychological behavior, spiritual beliefs, cognitive awareness, ability, and financial status, all of which may have a direct impact on progress toward goals.

Medication Reconciliation

Medication reconciliation is a formal assessment process for creating the most complete and up-to-date list of a patient’s medications, including those taken independently like vitamins, supplements, and other over-the-counter medications, and comparing this list to what is listed in their records.

Medication reconciliation may include comparing medications listed on hospital discharge sheets to those taken previously and those currently being taken in the home, and then documenting discrepancies and actions taken to resolve them. It includes assessing the list for potential adverse drug-drug, drug-food, or drug-condition interactions and medications that are known to be high-risk for error in administration.

The Home Health Conditions of Participation states a drug regimen review must be done that specifically addresses the identification of ineffective drug therapy and significant side effects, in addition to those already identified. If adverse or potentially harmful reactions occur, the physician must be notified.

In addition, several items on the OASIS address medication review and reconciliation and assist in the identification of patient/caregiver needs for the development of a patient-specific plan of care.

Providers looking to ensure medication reconciliation occurs at their facility need look no further than the MATCH (Medications at Transitions and Clinical Handoffs) toolkit available through the Agency for Healthcare Research and Quality (AHRQ). It incorporates the experiences and lessons learned by experts in the field and includes chapters on useful topics such as high-risk situations for medication reconciliation.

Things to keep in mind as you document include the length of time since the initial diagnosis and the patient’s:

  • Current knowledge of disease and management
  • Ability to manage the disease process
  • Compliance with the current treatment regimen
  • Desire to manage the disease independently


Assessment is the first step of the care planning process and begins with collecting, validating, categorizing, summarizing, and interpreting patient health information.


For Medicare patients, comprehensive assessment and OASIS data elements provide the template for a thorough and complete assessment.

It is critical that you can recognize the most important health information so that you can then move forward with synthesizing a care plan that encompasses their needs holistically.

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