HOME HEALTH CARE - NAHC



HOME HEALTH CARE

OPERATIONAL POLICIES

CASE MANAGEMENT

PURPOSE:

To assure quality and coordinated care for home care patients by providing guidelines for case management.

POLICY:

1. The Case Manager is always a registered nurse.

2. A Case Manager will be responsible for all admission visits.

PROCEDURE:

The Case Manager will:

1. Regularly evaluate and re-evaluate patient status.

2. Initiate, develop, implement, and revise the patient’s plan of care (POC).

3. Address all nursing diagnoses identified in the POC.

4. Provide education to patient / family / caregiver concerning knowledge deficits or needs regarding the patient’s condition.

5. Coordinate the total POC and conference with other disciplines involved in the case.

6. Report signs / symptoms signaling a change in patient condition to the patient’s physician.

7. Make a supervisory visit every 2 weeks when a home health aide is involved in patient’s care. If the case is a therapy-only case, the home health aide supervisory visit may be made by the registered therapist. Supervisory visits may also be delegated to the visit nurse.

8. Reassess the patient within 24 hours following a change in patient condition or discharge from a 24 hour or longer hospital stay.

9. Be the first discipline to visit the patient following hospitalization. The Case Manager will then re-assign disciplines as needed and re-write any Home Health Aide Assignment Sheets. This may be delegated to the visit nurse. Should the visit nurse make this visit, the Case Manager provides information essential to the case.

10. Be responsible for continuous review of all aspects of every patient on his/her caseload including;

Appropriate utilization of services

Ensuring continued skilled need

Monitoring of homebound status

Review of documentation in the medical record

Maintenance of interdisciplinary communication

Discharge planning

HOME HEALTH CARE

OPERATIONAL POLICIES

The Visit Nurse Will:

1. Provide quality care for home care patients by following guidelines determined by the case manager.

2. Receive assignments from Clinical Supervisor that have been determined by case manager.

3. Complete all assigned visits and communicate all pertinent clinical information to the case manager.

4. Visit notes will be due 48 hours after the visit.

5. All pertinent clinical information that is needed for case conference will be discussed with the case manager prior to the Case Conference. The visit nurse may not be required to attend, as determined by the Clinical Supervisor and/or Case Manager.

6. Be responsible for completing discharge OASIS when assigned to make a discharge visit.

1. Maintain oversight of therapy-only cases by participating in Case Conferences, collaborating with other disciplines, and maintaining contact with the patient and physician as appropriate.

APPROVED:

________________________________ ________________________________ Administrator Director of Home Health Care

Effective Date:

Annual Date of Review:

Reviewed/Revised Date:

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