Overview

The quote "If it is not written down, it did not happen" applies to medical records and clinical documentation. It can be expanded to include clarity, consistency, and quality.

Comprehensive, consistent, and complete clinical documentation is critical for home health care agencies for the quality of care to the patient and optimum reimbursement. Improving the quality of clinical documentation will significantly enhance the quality of care and patient satisfaction while reducing the risk of compliance issues during surveys. Compliance issues during the survey may lead to reimbursement delays or reductions.

Home Health Care Agencies should implement Clinical Documentation Improvement (CDI) programs to understand that clinical documentation starts at referral and must be managed throughout patient care (Admit through Discharge). Home care agencies should identify characteristics for quality documentation and implement a CDI program. Keeping clear, concise, complete, and congruent documentation will significantly improve the quality of care and patient satisfaction. It will also reduce the potential for claims denials and survey deficiencies.

Benefits of High Quality Clinical Documentation

Characteristics of Quality Documentation for Home Health Care Agencies

Home Health Care Agencies should implement Clinical Documentation Improvement (CDI) programs to understand that clinical documentation starts at referral and must be managed throughout patient care (Admit through Discharge). Home care agencies should identify key characteristics of the clinical documentation, come up with the right Clinical Documentation Improvement program, and use the right software platform with tools to monitor and improve the quality of clinical documentation.

The following are some of the key characteristics of clinical documentation that will help Home Care Agencies to improve quality, consistency, and patient satisfaction.

Document Visits
Complete
Consistent and Congruent
Compliance
Personalization
Continuity of care

Benefits of High-Quality Clinical Documentation

The following are some of the key benefits of high-quality clinical documentation that will help Home Health Care Agencies to improve their overall operational efficiencies.

Quality and Continuity of Care
Patient Satisfaction
Reimbursement
Survey
Care Coordination

Quality and Continuity of Care

Continuity of Care is critical to improving the quality of care and the prognosis for the patient. One way to accomplish continuity of care is to maintain continuity of the caregiver/employee. Since it is almost impossible for a home care agency to maintain continuity of caregiver, agencies should strive to accomplish continuity of care through documentation. The following are some of the steps home care agencies can take to assure continuity of care.

Develop an interdisciplinary care plan and document the care plan. This will ensure that each clinician addresses the same problems, goals, and interventions for the patients.
Provide access to clinical summary and past clinical notes of all disciplines to the clinician. This will enable the clinicians to view and familiarize themselves with the care that has been given to the patient.
Provide the ability to communicate the plan for the next visit to the next clinician. This plan should be easily accessible for the clinician for the next visit.
Note the changes in the patient's condition and update the care plan accordingly. This will enable the clinician for the next visit to provide care based on the updated care plan.

Following these steps will significantly improve the quality of care provided to the patient.

Patient Satisfaction

Providing high-quality care and improving the prognosis for the patient will improve patient satisfaction. Personalizing care for each patient based on the patient's health and service requirements and providing care based on a personalized care plan will improve the quality of care and patient satisfaction.

Reimbursement

Timely, accurate, and complete documentation will improve reimbursement and reduce claims denials.

For Medicare Certified Home Health Agencies, reimbursement is based on the Patient-Driven Grouping Model (PDGM). PDGM relies heavily on patient clinical characteristics to place the patient into payment groups. Complete and quality clinical documentation will improve the chances for accurate reimbursement for the payment periods for the patient.
Private Duty Nursing and Non-Medical Home Care Agencies may have to send supporting clinical documentation with claims for reimbursement. Timely, accurate, and complete clinical documentation will improve the probability of timely reimbursement and reduce claim denials.

Survey

Timely, accurate, complete, and quality clinical documentation will significantly improve the survey readiness for Home Health Care Agencies. Irrespective of the timing of the survey, clinical documentation is always ready for the survey. Having a Clinical Documentation Improvement program will reduce the survey deficiencies.

Care Coordination

Keeping accurate and complete clinical documentation and providing access to these documents to the clinician will improve the quality of care. This will help the care provider review records, assess the plan for the current visit, and adjust the care based on the patient's current condition. Agencies can also share the clinical documents with other care providers throughout the continuum of care.

Conclusion

Home Health Care Agencies should consider implementing appropriate Clinical Document Improvement (CDI) programs to improve quality of care, patient/employee satisfaction, compliance, and reimbursement.

CareVoyant Home Care Software platform provides home agencies with many tools to develop and implement a CDI program. CareVoyant for Home Care is an integrated, cloud-based software platform with easy-to-use communication tools for Home Health Care Agencies offering multiple services – Private Duty Nursing, Non-Medical, Personal Care, HCBS, and Home Health - under ONE Patient and ONE Employee making it a Single System of Record.

ABOUT CAREVOYANT

CareVoyant is a leading provider of cloud-based integrated enterprise-scale home health care software that can support all home-based services under ONE Software, ONE Patient, and ONE Employee, making it a Single System of Record. We support all home based services, including Home Care, Private Duty Nursing, Private Duty Non-Medical, Home and Community Based Services (HCBS), Home Health, Pediatric Home Care, and Outpatient Therapy at Home.

CareVoyant functions – Intake, Authorization Management, Scheduling, Clinical with Mobile options, eMAR/eTAR, Electronic Visit Verification (EVV), Billing/AR, Secure Messaging, Notification, Reporting, and Dashboards – streamline workflow, meet regulatory requirements, improve quality of care, optimize reimbursement, improve operational efficiency and agency bottom line.

For more information, please visit CareVoyant.com or call us at 1-888-463-6797.