{"ref":"TX-HH-CC-01","title":"Coordination of Services and Case Conferences","category":"Service delivery","summary":"Sets out how Agency staff, contracted staff, practitioners, other providers, and any facility where the patient lives share information and coordinate care, when case conferences are held, and how coordination is documented in the patient’s record.","inShort":["Every patient has a case manager who coordinates all their care. Know who it is.","Aides, LVNs, and therapy assistants: report changes in condition to the registered nurse or therapist the same day.","Write visit notes the day of the visit so the rest of the team can rely on them.","Record every call with a practitioner, another provider, or the patient’s facility that affects care: date, who, what was said, and what was done.","Join case conferences when asked. They are held before each 60-day review for patients with two or more disciplines, and after any big change."],"primaryCitation":"26 TAC §558.288","citations":["26 TAC §558.288","26 TAC §558.301"],"federalCitations":["42 CFR §484.60(d)","42 CFR §484.75(b)","42 CFR §484.105(c)","42 CFR §484.80(g)"],"surveyorAsks":["Show me how the nurse and the physical therapist coordinated this patient’s care.","This patient also goes to dialysis. Show me your communication with the dialysis center."],"forms":[{"ref":"TX-HH-CC-01-A","title":"Case Conference Record"}],"headings":["Terms of Reference","1. Purpose","2. Scope","3. Definitions","4. Policy Statement (26 TAC §558.288)","5. The Case Manager","6. Communication Among Agency Staff","7. Communication With Practitioners and Other Providers","8. Case Conferences","9. Education and Training of Patients and Caregivers","10. Services Under Arrangement","11. Responsibilities","12. Records and Compliance Monitoring","13. Staff Training","14. References","15. Related Policies and Forms","16. Approval","17. Revision History"],"version":"1.0","sample":false,"pack":"tx-lhhs","state":"Texas","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 Home Health Agency","legalName":"Sample Home Health Agency, LLC","logo":null}}