Coordination of Services

POLICY

Primecare Network & Medical Supplies staff shall participate in the coordination of client care services to establish effective interchange, reporting, and coordinated client outcomes through case conferences or other communication strategies.

PURPOSE

To ensure the provision of coordination activities for all home care clients.

PROCEDURE

• All staff members and contact staff are expected to participate in coordination activities as needed based upon the client’s needs.
• The supervisor is responsible for establishing and maintaining communication among all disciplines, agencies, and organizations involved in providing health and supportive services to the agency’s clients.
• Coordination activities may include, but are not limited to:
  1. Scheduled multi-disciplinary case conferences
  2. Individual patient care conferences involving one or more disciplines providing services to the client
  3. Telephone communication between individual staff members seeing the same client
  4. Use of voice mail messages between disciplines, staff, and/or supervisors
  5. Written memorandums to agency and community individuals involved in a client’s care
  6. Visits to hospitals and other institutions to coordinate and facilitate transfers, assess client’s home care needs, and/or coordinate the care of active home care clients who have been hospitalized
  7. Summary written, telephone, or verbal reports to clients’ physicians.
  8. Periodic case conferences with supervisors
  9. Review and revision of the client’s plan of care as needed, based upon changes in the client’s condition, situation, and environment
  10. Comprehensive assessments and reassessments and communication of the results to the client, family/caregiver, and other disciplines involved in the client’s plan of care
  11. Identification of the need for, and referral to other home care services
  12. Use of transfer and discharge summaries
• Subjects discussed in patient cause conferences or other coordination communications that may include, but are not limited to, the following:
  1. Arranging for the uninterrupted continuing care of the client
  2. Assisting in the organization of family resources for the effective care of the client
  3. Review of findings from client assessments and interventions to determine appropriate internal and external resources necessary to meet client needs
  4. Assisting in establishing a definitive home care plan prior to discharge from a hospital or long term care facility, including assessment of the appropriateness of the requested services
  5. Arranging for special medical supplies or appliances or arranging for training agency personnel regarding unfamiliar procedures or problems pertaining to the client’s care
  6. Communicating information regarding the client’s needs, goals of care/service, and/or interventions to be implemented by each individual
  7. Evaluation of the client’s care plan
  8. Coordinating the activities of the agency with the community resources needed in the care of the client
  9. Review of the appropriateness of continued delivery of home health care services to the client
• The content and results of any coordination activity are documented in the service record. The documentation includes, but is not limited to, the following:
  1. With whom the coordination activity was conducted, or the disciplines/participants present at the activity
  2. What was discussed during the coordination activity
  3. The outcome of the coordination (i.e., change in current plans, specific recommendations agreed upon by the participants involved in the coordination activity).
• Responsible/assigned staff will maintain on-going communication with the physician when services require physician orders, which includes both verbal and written reports that address the following, at a minimum:
  1. Any changes in the patient’s condition.
  2. Changes in the patient’s psychosocial status
  3. Results of laboratory tests
  4. Lack of achievement of home care goals within the specified time
  5. Changes in expected response to treatment or medication
  6. Changes in caregiver support or the home environment
  7. Patient’s response to care/outcome of care or services
• Coordination of care or services with other involved community organizations or individuals includes the following, at a minimum:
  1. Staff understanding of each organization’s responsibility in providing care or service
  2. Initiation of communication when there are significant changes in the patient’s overall care
  3. Absence of conflict or duplication of services provided by the various organizations serving the same patient

For more information, please feel free to contact us at your convenience.