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12/28/2012
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MEDICARE START OF CARESTEP BY STEP STEP BY STEP
Shirley Offutt BSN, RN
This training is Audio and PowerPoint
Please adjust the volume
Suggest using head/ear phone
For this training you will need:oProcess ManualoMedicare Admission POC (485)(SN, Aide, Therapy, SW)Guideline InstructionsoGuideline Instructions
oOASIS‐C Process Tracking Flow Charts
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CEU’s are awarded for this training.
To obtain CEU’s you must complete the following requirements:oView the entire training.oComplete and submit the Activity at the end of the training.
oComplete and submit the Evaluation form.
Verbalize understanding of the admission notification process.
Verbalize utilization of assessment skills during the home tour to appropriately answer OASIS items related to:
o SafetyoAmbulationoMedication
oADL’soPainoHearingo Incontinence
Verbalize correct method to document medications.
Verbalize F10 Orders for the nurse, aide, social worker, and therapist.
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Verbalize Goals related to the POC and Interventions.
Verbalize the use of the Clinical Note, Non‐Clinical Note and Note Section during the admission process.
This trainingwill not offer CEU's to any employee that is in their orientation phase. p
Lets discuss where information in each Locator on the POC is pulled from.
R f h P M l d “E bli hi Refer to the Process Manual under “Establishing the Plan of Care for Skilled Services” and “POC/485”.
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Review referral information (on paper or in laptop) for admission diagnosis and disciplines ordered.
Call patient/caregiver to schedule admission and i f ti t/ i th d i i inform patient/caregiver the admission process could take 2 ½ to 3 hours.
Take OASIS Teaching Handouts (should be in Patient Admission Packet) and an Advance Directive Form.
At time of admission:o IntroductionoReason for admissiono Inquire if receiving other home services q go Inquire if receiving outpatient therapy oComplete Patient Admission BookletoNever have the patient sign a blank Authorization Form or Request for Medical Records Protected Health Information Form
oComplete Referral Form and Loose Forms
Use observation skills to assess patient (enables adequate OASIS answers).
H i h i b i fHome tour with patient observing for:o Safety issuesoMedications on counter, bedside table, etc.oGait and proper use of assistive deviceo Shortness of breath when talking/ambulating
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oWhile in bedroom do head to toe physical assessmentoAbility to get clothes out of closet/drawersoEvidence of incontinence oAbility to transfer to and from shower/tuboAbility to transfer to and from shower/tuboAbility to negotiate stairs and a variety of surfacesoComplaints of pain or exhibits s/s of painoAdequate food supply oPatient’s ability to hear you talking in a normal voice while walking with them
Complete OASIS Assessment.
Complete patient information in Profile tree.
Discuss Plan of Care and realistic goals with patient/caregiver and begin Discharge Planning.
Ask patient to read medication bottles and tell you when and why they are taking the medication (checks vision and knowledge of
di i )medication).
Enter medication into Horizon according to the Medication Policy/Procedure and Process.
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o Oxygen is a medication.o List wound products such as: triple antibiotic or debridingagents, but not wound products in an impregnated dressing. Do not list wound cleaning products such as: kara clenz, betadine, peroxide etc.
o As needed medication should have PRN listed in frequency i D i i h di i O d N h ld section. Documentation in the medication Order Note should
indicate reason PRN is ordered and how often.o Insulin should indicate if taken in AM or PM not listed as Daily.
Review significant medication issues( refer to P & P and OASIS M items).
Add the following Guidelines on admission:oOASIS C Process Tracking GuidelineoAdmission GuidelineoNon Visit Guideline ( e.g., B 12, Catheter)oDisease Process Guideline for your focus of care, if G id li il bl ( b it ifi tt h d i Guideline available, (subunit specific, may attach during second visit)
oDischarge Guideline(subunit specific, may attach at discharge visit)
oFlu Guideline (during Flu season)
Start teaching from the OASIS‐C Process Tracking Guideline Interventions.
Complete teaching from the Admission Guideline.
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In Visit Content click on SN under “Items Available for Visit” and add the following to “Items in Visit”: A C H i li i F (ACH)oAcute Care Hospitalization Form (ACH)
oPHQ‐9 (if PHQ‐2 is 3 or greater)oPAINAID ‐ for patients unable to rate their pain using the 1‐10 scale
STOPSTOP
Call MD and discuss POC and diagnosis noted during assessment not listed on referral form.
SOC VO from Physician/Physician representative i i th d /H H lth i i th giving the order/Home Health nurse receiving the
order. (e.g., 1/31/2011 Evaluate for Home Health care and initiate ordered services VO Dr. Green/Suzie Sweet LPN/ Josie Joy RN).
Establish order of diagnosis in Profile.
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Primary focus of care (e.g., Assess and Instruct on CHF Disease Process and management).Disease processes listed on the POC but not the focus of care (e.g., Assess for s/s of exacerbation of disease processes and report abnormalities to MD).May F10 for orders and individualize according to patients needs.
Orders for medication assessment and teaching (e.g., Instruct patient/caregiver on medication regimen and management).regimen and management).
List procedures patient/caregiver performs and procedures SN may perform.
OASIS Process Measures (e.g., Monitor for presence of skin lesions on lower extremities and instruct on proper foot care).
Parameters, if ordered (e.g., Monitor O2 SATS without use of oxygen and report to MD if SATS are below 90; report fasting Blood sugar >120 and <58 and non‐fasting blood sugar >200 and < 60 to MD).
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Add Interventions (if applicable) for:oParameters (e.g., Report to MD O2 SATS less than 90 without use of O2; report fasting blood sugar >120 and <58 and non‐fasting blood sugar >200 and < 60 to MD).
oDisease process statement for the disease process that are not the focus of care (e.g., Assess for s/s of exacerbation of COPD, GERD and report abnormalities to MD).
NOTE: Consult your supervisor regarding placing reminders (PHQ‐9, Progress Note, LPN Supervisory Visit and Discharge Notice) in Non‐Supervisory Visit, and Discharge Notice) in Non‐Clinical Note or in Interventions.
oProgress Note reminder, SN to document in Intervention Note section date Progress Note is due.
oPHQ‐2, SN to document in Intervention Note section h D i S i i dwhen next Depression Screening is due.
oLPN supervisory visit, SN to document in Intervention Note section date supervisory visit is due.
oDischarge notice, SN to document in Intervention Note section date discharge notice to be delivered.
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May F10 for orders and individualize according to patient’s needs.
Create Admission Note via F10, filling in space h ldholders.
Create Telephony Care Plan according to patient’s needs.
F10 for MSW orders.
Case Conference Note.
Merit therapist will write their own orders and goals.
Consult your supervisor regarding orders for Consult your supervisor regarding orders for contract therapist. May write generic order (e.g., P.T. to eval and treat).
Case Conference Note.
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Consult your Supervisor/Educator.
Each discipline ordered must have a Goal(s) on the POC.
Goals must mirror the orders on the POC.
Goal for the Diagnosis related to the focus of care (e.g., Patient/caregiver will demonstrate knowledge and management of CHF, Patient will demonstrate compliance with taking medication via medi‐planner as prefilled with prescribed meds by skilled p p p ynurse).
Generic goal for assessing other diagnosis which are not the focus of care. (e.g., Patient will not exhibit s/s of exacerbation of disease processes).
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Goals for other orders (e.g., wound, process measures, parameters).
Add target date to each goal.Add target date to each goal.
Add Rehab Potential and Discharge Plans (no target date needed).
In our Operational Manual the Admission Process, indicates to use this section to enter visit assignments and Interventions. This section is not t f th t d th f th a part of the permanent record, therefore other information may be entered as related to patient care and alerts.
Example:− Call before seeing patient. Has big dog that needs to be chained up. Patient is mentally delayed, John Doe (father) is caregiver. If unable to reach father on home h ll ll h phone; call cell phone, 334‐400‐1234.
− Visit 2 (week of 1/3/11) Assess and Teach: Process Tracking Interventions, start HTN Guideline, observe caregiver filling med planner, continue medication teaching. Report B/P and BS (readings from glucometer) to MD.
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− Visit 3 (week of 1/10/11) Teach: Process Tracking Interventions and HTN. PHQ‐2 due. Assess compliance with med planner and observe caregiver filling med planner continue caregiver filling med planner, continue medication teaching. Report B/P and BS (readings from glucometer) to MD.
− Visit 4 (week of 1/17/11) Assess and finish teaching Process Tracking Interventions. Assess knowledge of HTN teaching and med compliance with med‐planner, continue medication teaching. Progress Note due, LPN Supervisory Visit due (if LPN utilized), discuss discharge, give discharge notice (if no orders to extend visits).
− Visit 5 (week of 1/24/11) Assess med compliance, finish medication teaching, attach Discharge Guideline and instruct. Notify MD of patient y pdischarge and report B/P and BS (readings from glucometer).
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Medicare does not require an Admission Summary on the POC.
Start of Care visit requires reasonable documentation that services are consistent with the regulations and guidance provided. This i l d t f i di l it d includes type of service, medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or services furnished have been completely and accurately reported.
The following should be included in the Clinical Note: oDescription of the patientoChronologically list History of Disease(s)oReason for hospitalization (if applicable)oHomebound status oDiagnostic Test (not listed in OASIS Assessment)oHome Support (not listed in OASIS Assessment)oLevel of Functioning (not listed in OASIS Assessment)oOther ServicesoAbnormalities (not listed in Guidelines, Wound Advisor, OASIS Assessment)
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Medical necessity should be documented in the Clinical Note. Examples may be:oRequires SN services to assess/eval/instruct on disease processes, med‐planner prefill, assess effectiveness of medication, and home safety. medication, and home safety.
oHome Health Aide needed to assist patient with personal care due to lack of caregiver.
oPhysical Therapy for therapeutic exercise, gait training, and establish home exercise program.
oMSW to assist with financial problems.
Document Flu and Pneumonia under Customer/Patient Note. Use Search button to find Vaccine Note. Example: oFlu vaccine given 11‐7‐2010 at Dr. Goodie’s office. oPatient wants Pneumonia vaccine, she will talk to Dr Goodie on her next visit. OR
oPatient does not want the Pneumonia vaccine.
Refer to OASIS‐C Process Tracking Flow Chart for documentation instructions.
