{"ref":"MO-HH-CC-01","title":"Coordination of Care, Case Conferences, and Written Information to the Patient","category":"Service delivery","summary":"Sets out how the Agency coordinates each patient's care: communication with every physician and allowed practitioner involved, integration of their orders and of services given directly or under arrangement, involvement of the patient and caregivers, ongoing education, case conferences (held as the Agency's own standard at each recertification and whenever the patient's condition or plan changes significantly), summary reports, coordination with other providers, and the written visit schedule, medication schedule, treatments, instructions and clinical manager contact details given to every patient under 42 CFR §484.60(e).","inShort":["Leave written instructions in the home: visit schedule, medicines, treatments and the clinical manager's contact.","Update the written instructions whenever anything changes.","Record every call with a physician or practitioner: who, when, what was said and any orders.","Tell the case manager the same day about anything that affects another discipline.","Take part in case conferences before each recertification and when the patient changes."],"primaryCitation":"42 CFR §484.60(d) and (e) (adopted by 19 CSR 30-26.010(1)(A))","citations":["19 CSR 30-26.010(1)(A)"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.60(e)","42 CFR §484.75(b)(7)","42 CFR §484.80(g)(4)","42 CFR §484.105(c)(2), (3)","42 CFR §484.105(e)","42 CFR §484.2"],"surveyorAsks":["Show me how the disciplines caring for this patient communicate with each other and with the physicians.","This patient has two physicians giving orders. How do you integrate their orders?"],"forms":[{"ref":"MO-HH-CC-01-A","title":"Case Conference Record"},{"ref":"MO-HH-CC-01-B","title":"Your Home Health Visit Schedule and Care Instructions"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60(d), (e); 42 CFR §484.105(c); 19 CSR 30-26.010(1)(A))","5. Coordination Duties","6. Communication With Physicians and Allowed Practitioners","7. Coordination Among Disciplines and Contractors","8. Case Conferences","9. Coordination With Other Providers","10. Patient and Caregiver Education","11. Written Information Left With the Patient","12. Schedule Changes and Missed Visits","13. Documentation","14. Responsibilities","15. Records and Compliance Monitoring","16. Staff Training","17. References","18. Related Policies and Forms","19. Approval","20. Revision History"],"version":"1.0","sample":false,"pack":"mo-hha","state":"Missouri","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}}