Overview

Tools to Improve quality of clinical documentation in Home Health Care

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 have a Quality Assurance group to review clinical documentation after it is completed to ensure accuracy, completeness, and quality. Checking for the quality of clinical documentation after the fact requires a lot of effort, potentially leaving unidentified issues with the documentation. Home Health Care Agencies should implement Clinical Document Improvement (CDI) programs to understand that clinical documentation starts at referral and must be managed throughout patient care (Admit through Discharge).

Even though complete and consistent clinical documentation is necessary, many home care agencies face challenges in maintaining quality documentation. Home care agencies should identify characteristics for quality documentation. Home Care Agencies should also have tools to monitor clinical documentation throughout the process to ensure the document's quality.

Challenges for Home Health Care Agencies:

Even though home care agencies use software for clinical documentation, they still face challenges in meeting consistent and quality documentation requirements in compliance with the physician's orders and plan of care. The following are some of the challenges they face:

Documenting all visits timely
Ensuring complete clinical documentation
Documenting the changes in patient conditions and recording the progress
Documentation is compliant with the physician's order and plan of care
Documentation is consistent with the patient's condition and the services provided
Communicating plan for the next visit for the next clinician

Home care agencies should identify key elements of clinical documentation, develop a process to ensure complete and timely documentation, and select the right tools to monitor the quality and consistency of the documentation.

Characteristics of Quality Documentation for Home Health Care Agencies:

Home Health Care Agencies should implement Clinical Document 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 documentation.

Document Visits
Complete
Consistent and Congruent
Compliance
Personalization
Continuity of care

Document Visits

Each home care visit must be documented. If the visit is not documented, it did not happen. Without visit documentation, it will be very difficult to prove that the visit actually happened. When the visit did not happen, it must also be documented as missed visit. Missing documentation for a visit will lead to reimbursement and compliance issues affecting the bottom line for the agency. Home care agencies should have tools to proactively identify the visits without documentation and follow up with clinicians to complete the documentation. This will help home care agencies complete documentation promptly, reducing delays in billing and reimbursement.

Complete clinical Documentation

Clinical documentation should be complete with all the required sections and fields completed before signing off on the documentation. Allowing the employees to complete and sign off on a visit without completing the documentation will lead to additional time and effort during the Quality Assurance process. This will also lead to deficiencies at the time of surveys. The Quality auditors must validate the visit's documentation for any errors. The employee or caregiver should not sign the clinical note until all the errors are corrected.

Consistent and CongruenT

The documentation should be consistent with the type of service provided during the visit. Linking the documentation with the type of scheduled service and defaulting required forms will help clinicians complete the right conditions for a visit. Providing documentation of all services provided to the patient will enable the clinicians to identify any inconsistencies with the document and make the services congruent.

Compliance

Visits and documents should be compliant with the visit frequency established by the physician. Linking the schedules to physician's order and frequency and documenting based on the schedule will keep the agency in compliance with orders. Agencies should also maintain an interdisciplinary care plan and document the care plan. This will enable agencies to be compliant with the current care plan, not the one established at the beginning of the episode.

PersonalizatioN

Personalizing care for each patient based on the patient's health and service requirements is critical for the quality of care. Even though it is easy and quick to use care plan templates to develop care plans, agencies should look for ways to personalize care plans for each patient. This will help clinicians to provide care and document based on the personalized care plan. Clinicians should also add personalized comments while completing an assessment and documenting problems, goals, and interventions. Agencies should also look for ways to identify risk areas during assessment and develop a personalized care plan for the risk areas.

Continuity of Care:

Continuity of Care is very critical to improve the prognosis and patient satisfaction. 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. 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.

Conclusion

A software platform should provide the necessary tools to help home care agencies to develop and implement appropriate Clinical Document Improvement (CDI) programs to improve quality of care, patient satisfaction, compliance, and employee satisfaction.

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, 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.