Coordination of Services, Case Conferences, and Referral to Community Agencies
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.
About this policy
- Policy number
- NC-HH-CC-01
- Version
- 1.0
- Main rule
- 42 CFR §484.60(d)
- Library
- North Carolina home health · 57 policies
- Category
- Service delivery
- Sections
- 19
In short
- 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.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- 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
An inspector may ask
- 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?
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