Policy Manual sample

MDT Home Health Care Agency, Inc. CLIENT’S CASE MANAGEMENT POLICY: Home Health Care Agency Registered Nurses provide Client’s Case Management according to Home Health Agency policies and procedures. PURPOSE To ensure efficient and effective case management, facilitating exchange of information, coordination of care among staff, following all Patient’s privacy rights. Coordination of care. Our HHA must: (1) Assure communication with all physicians involved in the plan of care. (2) Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. (3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. (4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. (5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. PROCEDURES 1. Home Health Care Agency’s clients are accepted for admission to the Home Health Agency according to Policy and Procedures: Acceptance of Referrals for Home Health Care. 2. The Home Health Care Registered Nurse: a. Obtains the attending physicians, PA, ARNP (Advanced Registered Nurse Practitioner), acting within their scope of practice, verbal and written order for admission of the client to the Home Health Care Agency. b. Obtains the attending physicians, PA, ARNP (Advanced Registered Nurse Practitioner), acting within their scope of practice, written certification that: 1. Home Health Care Services are and were required because the client is and was confined to the his or her home. 2. The client needed Skilled Nursing care on an intermittent basis or needed a physical, occupation, or speech therapy services. 3. A plan for furnishing Home Health Care Services (including all discipline ordered) to the client has been developed within 48 hours after the initial visit and reviewing as requirement or not less than 60 days. 4. Home Health Care Services are and were necessary and reasonable for the treatment of the clients illness or injury. 5. Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP). (Medicare recipient patients) c. Obtains the attending physician, PA, ARNP (Advanced Registered Nurse Practitioner), acting within their scope of practice, written Plan of Treatment and orders that incorporate physician - ordered home health care services. 3. The Home Health Care Registered Nurse initials home health care visits. The Registered Nurse: L-8 Home Health Agency Client Assessments