{"ref":"OH-HH-CC-01","title":"Coordination of Care and Communication with Practitioners","category":"Service delivery","summary":"Makes sure every discipline, contractor and practitioner involved in a patient’s care works from one integrated plan: the clinical manager coordinates care; the Agency communicates with all practitioners and integrates their orders; staff report changes; case conferences are held; the patient and caregivers are involved and educated; each patient receives written visit, medication and treatment instructions with the clinical manager’s contact details; and waiver case managers are kept informed.","inShort":["Report any change in the patient’s condition to the case-managing nurse or therapist the same day, or before you leave if it is urgent.","Document every visit and every call with a practitioner the same day.","Take part in case conferences for patients you share with other disciplines.","Make sure the patient has a written visit schedule, medication schedule and the clinical manager’s contact details.","For waiver patients, the Agency keeps the waiver case manager informed of significant changes."],"primaryCitation":"42 CFR §484.60(d)","citations":["OAC 5160-44-31(B)(8)","OAC 5160-45-03(B)"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.60(e)","42 CFR §484.75(b)","42 CFR §484.105(c)","42 CFR §484.80(g)(4)"],"surveyorAsks":["How do you coordinate the care of a patient seen by a nurse, a therapist and an aide?","Show me the record of your last case conference for this patient."],"forms":[{"ref":"OH-HH-CC-01-A","title":"Care Coordination Conference Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (42 CFR §484.60(d))","5. Who Coordinates","6. Communication Among Agency Staff","7. Communication With Practitioners","8. Case Conferences","9. Involving and Educating the Patient and Caregivers","10. Written Information to the Patient","11. Waiver Case Managers and Other Providers","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":"oh-hha","state":"Ohio","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}}