{"ref":"NC-HH-CC-01","title":"Coordination of Services, Case Conferences, and Referral to Community Agencies","category":"Service delivery","summary":"Makes sure every patient’s care is coordinated: communication with all ordering practitioners, integration of all orders and of every discipline and contractor, case conferences, involvement and education of the patient and caregivers, documented coordination whenever a patient receives more than one service, the NC Medicaid coordination rules (private duty nursing, home infusion, nutrition therapy, hospice, CAP), and referral to and from community agencies.","inShort":["Each patient has a case manager who coordinates all disciplines and doctors.","Tell the case manager the same day about any change, safety concern or missed visit.","Patients with more than one service have a case conference before each recertification and before discharge.","Ask what other services the patient gets (private duty nursing, infusion, hospice, CAP) so care is not duplicated.","Refer patients to community help they need, with their consent, and write down the result."],"primaryCitation":"42 CFR §484.60(d)","citations":["10A NCAC 13J .1001(a)(11)","10A NCAC 13J .1101(8)","10A NCAC 13J .1106","10A NCAC 13J .1111(a)","10A NCAC 13J .1402(a)(2)","NC Medicaid Clinical Coverage Policy 3A"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.75(b)","42 CFR §484.105(c)"],"surveyorAsks":["This patient gets nursing, physical therapy and aide services. Show me the evidence that the disciplines coordinate.","How do you find out what other services a patient receives?"],"forms":[{"ref":"NC-HH-CC-01-A","title":"Case Conference and Coordination Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60(d); 10A NCAC 13J .1001(a)(11))","5. Roles","6. Communication With Practitioners","7. Coordination Among Disciplines and Contractors","8. Case Conferences","9. Involving and Educating the Patient and Caregivers","10. Other NC Medicaid Home Care Services and Hospice","11. Referral To and From Community Agencies","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":"nc-hha","state":"North Carolina","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}}