2018 COP UPDATES FOR CLINICIANS (CONDITIONS OF PARTICIPATION)

Transcription

1 2018 COP UPDATES FOR CLINICIANS (CONDITIONS OF PARTICIPATION) 1

2 HEALTHWYSE HAS RESPONDED TO THE CHANGES IN COPS BY UPDATING THE SOFTWARE TO FACILITATE COMPLIANCE WITH THE NEW REGULATIONS The COPS were updated to improve quality of patient care, outcomes and care coordination. Clinicians will see the following areas have been enhanced to meet the new regulations. Patient Rights Comprehensive Assessment Plan of Care Care Coordination Infection Control Home Care Aide Supervision Emergency Preparedness Administration and Oversight Clinical Records 2

3 PATIENT RIGHTS Clinicians will see the following in the Admissions Packet and in the Patient Rights Tab in OASIS: OASIS Rights Agency Transfer and Discharge Policies How to report a grievance 3

4 COMPREHENSIVE ASSESSMENT Each patient must receive, and the HHA must provide, a patient-specific, comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: The patient s current health, psychosocial, functional, and cognitive status The patient s strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient, and the measurable outcomes identified by the HHA, the patient s primary caregiver(s), if any, and other available supports, including their: (i) Willingness and ability to provide care, and (ii) Availability and schedules 4

5 CHANGES TO ATTRIBUTES TO MEET THE NEW COMPREHENSIVE ASSESSMENT REGULATIONS: New Patient Attributes Required: Category Patient Support System Primary Caregiver Patient Representative Note: Representative and Caregiver MUST also be entered in Contacts list, and may be selected from the dropdown to complete the Attribute 5

6 CHANGES TO OASIS TO MEET THE NEW COMPREHENSIVE ASSESSMENT REGULATIONS- RISK PROFILE Risk Profile -located in the History Tab Assessed risk for Emergency Room use Assessed risk for Hospitalization All patients with CHF, COPD, 02 dependence, multiple medications, history of ER and unscheduled Hospital stays in the past year should be deemed high risk. Others will be considered moderate risk. Note: If there is no reason why ER risk is different from Hospital risk, state they are the same. Clinical Assistant contains required Patient Risk Order 6

7 CHANGES TO OASIS TO MEET THE NEW COMPREHENSIVE ASSESSMENT REGULATIONS- CARE PREFERENCES Additions to OASIS Assessment (ADL Tab): Patient Strengths Patient Goals Patient s Care preferences Caregiver ability, willingness, availability Clinical Assistant contains the required orders for Patient Goals and Care Preferences 7

8 CARE PLAN Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patientspecific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. 8

9 NEW CLINICAL ORDERS TO MEET THE ENHANCED CARE PLAN REGULATIONS New Clinical Orders: New Head to Toe Assessment for High risk patients allows clinicians to enter Head to Toe Assessment with one click. Patient Personal Plan: Patient stated Goal and Patient identified steps toward Goal achievement (Also located in Clinical Assistant) New Head to Toe assessment to be added by SN for all patients with high risk for ER or Hospitalization Advance Directives now display on the 485, and populate from the Patient Attribute: Directives Every plan of care must include patient s personal goal and steps Advance Directives identified now to meet displa personal goal 9

10 OASIS PLAN OF CARE SYNOPSIS INTERVENTIONS (CLINICAL ORDERS) OASIS Plan of care synopsis Interventions were created to increase the ease of creating a Care Plan that meets the required process measures. For every patient requiring an OASIS, the plan of care should include the appropriate OASIS POC synopsis interventions. The OASIS POC Interventions address the following and include patient and caregiver education: 1. Goals to address functional status including transfers, ambulation, bathing, and dyspnea. 2. Interventions to address fall prevention, general and high risk medication education, and pain management. 3. Interventions for diabetic patients that include skin exams and foot care. 4. Interventions for patients at risk for skin breakdown. 10

11 OASIS POC SYNOPSIS INTERVENTIONS ARE SELECTED FROM THE PICK LIST 11

12 PATIENT RISK FOR EMERGENCY ROOM USE AND HOSPITALIZATION PATIENT CARE PREFERENCES IDENTIFY AND ADDRESS- NEW CLINICAL ORDERS Risks for ER visits and Hospitalization are documented via the new Risk Profile in the History tab of the OASIS The Patient Risk Clinical Order must be entered for all patients at medium to high risk for *Note- Head to Toe, Patient Personal Plan and Patient Risk Status orders are located at the bottom of the Clinical Orders list. Patient Risk and Personal Plan may be selected from the Clinical Assistant at the bottom of associated assessment forms in the OASIS. Hospitalization. 12

13 CARE COORDINATION The HHA must provide the patient and caregiver with a copy of written instructions outlining visit schedule, medication schedule/instructions, and treatments to be administered Use clinical interventions and Careplan documentation to guide teaching patient and caregivers, in preparation for patient discharge. Coming soon! Checklist to leave with patient which includes interventions and DC plan Note: Plan of care must be communicated to the physicians, patient, caregiver and/or caregiver representative. Verbal Orders are sent to the MD for signature and Quick Notes are used to document communications. 13

14 INFECTION CONTROL- REMINDER COMPLETE INFECTION REPORT FOR HOMECARE ACQUIRED INFECTIONS The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA s quality assessment and performance improvement (QAPI) program. Add the Infection Report for ALL homecare acquired infections. Do not use the Infection Report if the patient was admitted to homecare with an Infection! 14

15 EMERGENCY PREPAREDNESS-REQUIRED FIELDS The HHA must comply with all applicable Federal, State, and local emergency preparedness requirements. The HHA must establish and maintain an emergency preparedness program. Admitting clinician must complete Emergency Preparedness Assessment, and create Evacuation Plan if needed. Review the assessment with the patient/caregiver including information regarding Emergency plan options in the Admission Packet. Assign the Patient Priority Level and Complete Special Needs list in OASIS 15

16 HOME CARE AIDE SUPERVISION-UPDATED PERFORMANCE FIELDS Home health aide supervision must ensure that aides furnish care in a safe and effective manner. Updates to the HCA Supervision checklist align with new regulatory requirements Following the patients plan of care Maintaining open communication Demonstrating competence with assigned tasks Complying with infection prevention and control Reporting changes in patient condition Honoring patient rights 16

17 ADMINISTRATION One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following: (1) Making patient and personnel assignments. (2) Coordinating patient care (3) Coordinating referrals. (4) Assuring that patient needs are continually assessed. (5) Assuring the development, implementation, and updates of the individualized plan of care. Clinical Managers will be providing oversight You will see the Clinical Manager Assigned to the patient listed in Attributes 17

18 CLINICAL RECORDS The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) issuing orders for the home health plan of care, and appropriate HHA staff. Per regulation, the electronic signature date and time has been added to all clinical documentation. The actual date and time when you sign a visit is added to your visit note signature, regardless of the date of the visit. 18

19 DISCHARGE SUMMARY A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient s discharge; A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient s care will be immediately continued in a health care facility. Agency and Discipline Discharge Summaries must be completed at the time of Discharge DC summaries must include brief summary of Care Provided, patient Goal Status, the post DC plan, including any referrals made. All DC Summaries will be delivered or faxed to physicians Transfer Summary to be completed in a timely fashion. Delivery will be managed from OfficeWyse. 19