Care Planning for HHVPB/ ACOs and Outcomes


Published: 1/1/0001

Home Health is changing rapidly, the most successful HHA have been making changes to all aspects of their businesses.  Care planning is no exception.  Alternative care models such as ACO’s along with value based purchasing, make a HHA’s care plan more important than ever.  Care planning for the decreasing length of stay in home care means HHAs have to be more concise and highly focused.  OperaCare teaches care planning should always start with a 30 day / 6 skilled nurse visits plan.

Below are questions to consider about your agencies care planning:

  • Who is generating your Plan of Care?

As margins continue to narrow and HHAs are increasingly called to met goals and produce patient outcomes, WHO is producing the care plan becomes more important.  OperaCare teaches QA/ management staff with knowledge of evidence based practice should be producing care plans.  These nurses typically have a much better understanding of value based metrics than your field clinician.  HHA must provide concise interventions in fewer visits while meeting goals.

  • What Interventions and goals is your agency using?

Most of the leading HH EMR’s have interventions and goals within their body system assessments.  During PPS, before margins were decreased, field nurses picking interventions and goals as they went insured there were plenty of tasks to keep the nurses busy -and a reason for recertification.  However, these interventions and goals vary greatly by clinician and make outcomes harder to reach.  Input must be consistent to produce outcomes consistently.  OperaCare believes providing diagnosis based care planning will ensure HHAs remain focused on the reason for the referral, meet goals, and prevent readmissions.

  • When is the Plan of Care created?

Care plans must be produced quickly.  OperaCare suggests the same day the OASIS visit is done. Field staff without care plans tend to teach on fall prevention, bathroom safety etc., or the patient visits are delayed waiting for orders.  Delaying the POC increases the risk of re-hospitalization.

  • How do you know your interventions and goals are effective?

QIO/QIN networks along with HHQI have provided an enormous amount of evidence based, disease specific information for us.  Taking advantage of this information to produce care plans will ensure you are providing effective patient care.  OperaCare provides a small library of evidence care pathways along with training to HHAs who want to make their own.  Having evidence base disease specific care plans fully produced which can be imported straight into your locator 21 will proved accurate consistent care for your patients and expedite the care planning process.

Kristi Bajer BSN, RN is the VP of Clinical Operations at OperaCare LLC.  A data driven automated QA platform which ensures compliance and revenue integrity.