{"ref":"LA-HSP-IDG-03","title":"Coordination of Care, Continuity and Case Management","category":"Hospice care","summary":"Sets out how the Agency meets each principle of LAC 48:I §8221.C: an RN case manager for every patient, communication among disciplines, who may take verbal orders, professional management of contracted services, coordination with Medicaid and other providers, emergency care and hospital admissions, transfers, the Act 480 duties for patients in facilities, and professional boundaries.","inShort":["Each patient has an RN case manager who coordinates all care. Tell that nurse about any change the same day.","Only a licensed nurse, nurse practitioner, pharmacist or physician takes a verbal order. Record it, read it back and sign it at once.","Aides, homemakers and volunteers never take orders.","When a patient goes to the hospital or moves, share the plan of care, medications and LaPOST the same day.","Keep professional boundaries with patients and families."],"primaryCitation":"LAC 48:I §8221.C","citations":["LAC 48:I §8221.C.1-16","LAC 48:I §8223.A.3","LAC 48:I §8235.D.2.i-n","LAC 48:I §8217.H.2.i","LAC 48:I §8217.I.1.b.v-vi","LAC 48:I §8233.I-J","LAC 48:I §8237","R.S. 40:2009.26","Louisiana Medicaid Services Manual, Chapter 24 (Hospice), §§24.2, 24.7"],"federalCitations":["42 CFR §418.56(e)","42 CFR §418.106(b)","42 CFR §418.100(e)","42 CFR §418.24(c)-(d)"],"surveyorAsks":["Who coordinates this patient’s care, and how do the other disciplines know what is happening?","Who may take a verbal order here, and how is it recorded?"],"forms":[],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (LAC 48:I §8221.C)","5. Principles of Coordination","6. Case Management and Communication Among Disciplines","6.1 Orders","7. Contracted Services and Services Under Arrangement","8. Coordination With Other Providers and Medicaid Programs","9. Emergency Care, Hospital Admissions and Transfers Between Settings","10. Patients in Facilities","11. Professional Standards and Boundaries","12. Responsibilities","13. Records and Compliance Monitoring","14. Staff Training","15. References","16. Related Policies and Forms","17. Approval","18. Revision History"],"version":"1.0","sample":false,"pack":"la-hospice","state":"Louisiana","service":"Hospice","guides":[{"path":"/guides/hospice-policies/","h1":"What policies are required for hospice?"},{"path":"/guides/hospice-conditions-of-participation/","h1":"Hospice Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}