{"ref":"MI-HH-CC-01","title":"Coordination of Care, Case Conferences, Summary Reports, and Coordination With Home Help and MI Choice","category":"Service delivery","summary":"Sets out how the Agency coordinates each patient's care: communication with every physician or allowed practitioner involved in the plan of care, integration of all orders and of all services (direct and under arrangement), involvement of the patient, representative and caregivers, ongoing education and training, case conferences among disciplines, summary reports to practitioners, and, for Michigan Medicaid patients, coordination with Home Help and MI Choice so that services are not duplicated and do not happen at the same time.","inShort":["Document every visit the same day so the whole team sees current information.","Tell the case manager and the other disciplines the same day about any fall, new wound, medicine problem or safety risk.","Take part in the case conference held at least once every 60 days for patients with more than one discipline.","If two practitioners give orders, check for conflicts before you give the care.","For Medicaid patients with Home Help or MI Choice, contact the other program so aide tasks and times do not overlap."],"primaryCitation":"42 CFR §484.60(d)","citations":["Michigan Medicaid Provider Manual, Home Health, Sections 3, 4, 5, 8, 11, 11.1 and 11.2"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.60(c)(1)","42 CFR §484.75","42 CFR §484.75(b)","42 CFR §484.105(c)(2)","42 CFR §484.2"],"surveyorAsks":["How do the disciplines caring for this patient share information? Show me the last case conference for this patient.","This patient has orders from two practitioners. How do you integrate them?"],"forms":[{"ref":"MI-HH-CC-01-A","title":"Case Conference Record"},{"ref":"MI-HH-CC-01-B","title":"Home Help and MI Choice Coordination Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60(d))","5. Communication Within the Agency","6. Case Conferences","7. Communication With Physicians and Allowed Practitioners","8. Services Under Arrangement","9. Involving the Patient and Caregivers; Education","10. Coordination With Home Help and MI Choice (Michigan Medicaid)","11. Coordination With Other Providers and Programs","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":"mi-hha","state":"Michigan","service":"Home health","guides":[{"path":"/guides/home-health-agency-policies/","h1":"What policies and procedures are required for home health agencies?"},{"path":"/guides/home-health-conditions-of-participation/","h1":"Home health Conditions of Participation: which policies each one needs"}],"agency":{"name":"Sample Agency","legalName":"Sample Agency, LLC","logo":null}}