Posts Tagged ‘Home Care Coding’

Post-Hospital Syndrome (Updated): Is Home Health Prepared to Intervene?

Monday, March 17th, 2014

While Home Health Agencies are strengthening their “Falls Risk Programs” and looking at ways to reduce hospital readmissions, are we missing a structured program to expand our overall patient assessment to potentially combat “post-hospital syndrome? There were several questions provoked by this article so, a follow-up seems to be in order.


The New England Journal of Medicine published an article about Post-Hospital Syndrome- An Acquired, Transient Condition of Generalized Risk in early 2013. Have you read much follow up? Rehospitalizations remain an ongoing problem. Should we focus attention on this research? The research found that patients who are hospitalized, then discharged, are not only recovering from their acute illness, but they also experience a transient period of generalized risk for a wide range of adverse health events. Patients hospitalized for one condition may become so weakened that they become vulnerable for a very different condition. Post acute caregivers usually focus efforts of care on issues related to the acute condition that necessitated the hospitalization. The clinical care plan should reflect aftercare for the acute condition as well as the related conditions associated with the post hospital syndrome.

The research shows that one fifth of Medicare patients discharged from the hospital develop another acute condition and that condition requires another hospitalization within 30 days. Many of those patients were readmitted for heart failure, pneumonia, COPD, infections, GI conditions, mental illness, and trauma (Krumholz, www.ncbi,,

How does this syndrome occur? Hospitalization can be stressful at many levels. Patients frequently cite pain, sleep disturbances, and disruption of normal circadian rhythms. They complain of poor nourishment due to decreased food choices or meals cancelled or postponed meals due to tests. Patients frequently receive medications that can alter cognition, and negatively impact physical functioning.
Assess meds carefully. Look for signs of altered or diminished cognitive functioning. Listen carefully/

Generalized weakness can occur due to decreased physical activity and confusion or disorientation can be experienced due to altered daily activities coupled with altered sleep patterns and anxiety. Assess sleep patterns. Look for signs and symptoms of confusion.

Researcher, Dr Harlan Krumholz states that hospitalization can adversely affect health and cause an inability to fight off disease. He states hospitalized patients suffer from reduction in sleep time and REM time. This deprivation negatively affects “cognitive performance, physical functioning and coordination, immune function, coagulation cascade, and cardiac risk”. Patients experience more pronounced “jet-lag” type disabilities which includes dysphoric mood, cognitive impairment , and GI disturbances. Assess for signs and symptoms of depression.

Nutritional issues take their toll showing, in one study, that 1/5 hospitalized patients over 65 suffer a 50% decrease in calculated energy requirements. These deficits are usually not discussed at discharge, even though the patients frequently are suffering from protein energy malnutrition with weight loss and decreased blood albumin levels. Nutrition is coming to the forefront as one of the chief predictors of outcomes. Malnutrition, even short term, has been found to impair wound healing, decrease cardiac and respiratory function, and cause or exacerbate GI disorders. Discussing their meals planned and who is preparing them.

Pain with unpredictable hospital schedules impacts cognition and can cause mood disturbance, hypercatabolism, immunosuppression, and hypercoagulability. Assess pain levels and whether this is acute or chronic pain.
Over sedation can impact senses and impact judgment. Discuss hospital sedation and whether the patient is being sedated presently. Impaired stamina and strength conditioning can lead to a type of post-traumatic stress disorder.

Discharge Planners

The article suggests that discharge planners have an opportunity to educate patients and their families as to the potential syndrome. Just the shear fact that loss of functional dexterity, stamina, and muscle strength can suggest the potential need for home health care. What is the patient’s plan for self efficacy?

Home Health Care

Home health Agency personnel should be knowledgeable regarding the syndrome and the potential consequences of the recent hospitalization on their patient. They should be aware of the potential sleep disturbances that can occur in the hospital and the resulting consequences. They should assess for cognitive performance, decreased functional dexterity, and increased cardiac risk due potentially to syndrome caused disturbances. They should assess for confusion that may have been situationally or environmentally induced.

The assessing clinician should engage the patient in conversation to assess nutrition in the hospital. Weight should be noted. If there is a wound, healing will need to be assessed. Being aware of increased infections and pressure ulcers, along with decreased respiratory and cardiac function will allow the clinician to expand their assessment in these areas.

OASIS requires a functional assessment and with a recent hospitalization, loss of muscle tone, muscle strength, and stamina place the patient at greater risk for falls. It also places the patient in a weaker position to follow through with discharge instructions. They may need encouragement and assistance to keep physician appointments. Does your program and Integrated Care Model encouraging the use of motivational interviewing and moving patients toward self-efficacy?

Inadequate assessment can result in rehospitalization for falls, heart attacks, GI disorders, and other conditions. The physician researcher reminds the reader of Hillary Clinton’s hospital admission in 2012. She suffered from a GI disorder which caused dehydration and weakness which led to a fall resulting in a concussion. Trauma to her head led to the blood clot and the resulting rehospitalization.

Preventing rehospitalization now also requires attention to post hospitalization syndrome along with the original reason for the hospital admission. An assessment for post hospitalization syndrome should be considered for every patient in this category.

2014 Calendar of Change: OIG, PECOS, HIS, Hospice, OASIS C-1, HH-CAHPS, PPS, and ICD-10 CM

Wednesday, February 12th, 2014

WOW! It will be quite the year. Is your calendar marked? Are you planning? Will you be ready?

Home Health agencies are accustomed to change, but 2014 will be testing even the best of agency stamina. Hospices will see unprecedented new hospice reporting requirements. Below are certain regulatory dates and some suggested dates to begin to or continue preparation for certain changes scheduled:


  • Saw the reduction of payments to home health agencies by 1.05% as the 2014 PPS Final Rule takes effect.
  • Effects for Coding Case Mix began, as CMS removed 170 ICD-9CM Case Mix Codes including the infamous GERD. That code removal should have been no real surprise to anyone. GERD was much reviewed and critiqued by CMS. Most of the codes removed, however, had little impact upon home health.
  • Changes to the Medicare Benefit Policy Manual (MBPM) as a result of Jimmo vs Sibelius take effect.
  • MACs could now begin denying home health claims if physician NPI numbers were not on record in the PECOS system.
  • Hospices could begin submitting data on two Hospice Quality Reporting Measures; the Pain Measure and the structural measure which were collected in 2013.
  • Hospices could voluntarily report new medication claims data.
  • Mid January meant Q3 2013 HH-CAHPS data was due.
  • 1/31 Bundled Payment demos listed in CMS announcement. 90 of the 160 post- acute agencies listed were home health agencies. Keep a watch on this project as it could tell much about the future of home health payment.
  • 1/31 CMS temporarily suspends enrollment of new home health agencies in Fort Lauderdale, Detroit, Dallas, and Houston. The moratorium was extended in Miami-Dade and Chicago metro areas. Experts will not be surprised if a later announcement includes Baton Rouge, Brooklyn, LA, and Tampa (HEAT locations under focus).

HHS announced a delay for third level appeal ALJ reviews by more than 2.5 years, meaning an appeal filed in January would not be heard before July 2016. Current backlog is 357,000 claims for the 65 ALJs with 15,000 hearing requests being filed weekly.

Agencies should pay attention to OASIS Q&As released1/21 by CMS. Neither an adaptive reader nor a magnifying lens is considered corrective lenses, so please stop losing the two case mix points for M1200 by answering incorrectly if your team fell into this category.. Those two items were not what CMS was considering when they stated “corrective lenses.”


FEBRUARY- CMS is expected to issue Surveyor instruction regarding when and how to impose sanctions under the most recent Guideline revisions.

Training will be provided by CMS regarding the new Hospice Item Set (HIS).
Agency leaders should consider evaluating current patient mix to determine financial impact of ICD-10 transition. Agency leaders should consider outside audit of Coding. Review individual coders as to indepth knowledge of Anatomy, Physiology, Diagnostics, Pathophysiology, and Pharmacology. Consider third party coding specialists as an option. Look at their coder requirements, supervision and audits of coders’ work product and ask if they have an outside independent audit completed on their coding overall?

Palmetto is probing certain HIPPS codes of 20 therapy visits or more. The HIPPS codes under review are 5BHK, 5CHK, and 5CGK. These patients would have fairly high to high clinical and functional severity scores. These HIPPS codes are usually reviewed by agency QI departments.


MARCH – The first week of the month is CMS ICD-10 CM testing week. This will be followed by a meeting of the ICD-9 Coordination and Maintenance Committee Meeting.

CMS is to deliver an address to Congress regarding ways they believe the home health payment system should be revised.
Agencies may wish to develop more extensive intake process, guideline, and tool for intake in relation to ICD-10.
Review OASIS C1 with personnel.
The last day of the month is the deadline for open enrollment for individuals through the health exchange.

Consider Preparation of Coding Corporate Compliance Plan

Prepare for Cash flow interruption with the advent of ICD-10 as CMS states they expect a minimum of 10% rejection of claims due to inaccurate or non- specific ICD-10 codes.

Identify when Software Vendors will have new HIS tool ready in April to view.


APRIL- Hospices must comply with reporting new claims data that includes listing injectable and non-injectable prescription drugs on claims on line-item basis.

April 1 is the deadline for submission to CMS of both hospice quality measures; pain and structure measures collected in CY2013.

Agencies should be educating clinicians as to use of new OASISC1 that will be implemented July 1, 2014.

If coding is being done in house, begin practicing ICD-10 coding.

Conduct ICD-10 documentation expectation training for clinicians. Coding audits of documentation should be well underway. Finalize any new forms needed for ICD-10. Test tools and processes.

Develop refined audit tools for parallel coding if coding is not being completed by a third party coding firm.

Monitor readiness of payors, vendors, and clearinghouses for ICD-10 readiness.

April 14, Hospices will be required to report data on number and length of visits for clinicians and hospice aides.

April 17, Deadline for submitting Q3 HH-CAHPs data


MAY – Evaluate the understanding of OASIS C1, new tools, and forms for ICD-10 including a more extensive Intake tool. More clinical and diagnostic information will be needed up front to code properly. Test new intake assessment tool as assistance to the field clinician and the ICD-10 Coding specialist. If coding is inhouse, parallel coding should be underway to reduce the 40-50% projected increase in time required to code using ICD-10. Review ICD-10 Corporate wide Coding Compliance Plan Hospices educate personnel on new HIS tool. Evaluate time and processes for implementation in July. CMS will be offering training on HIS (TBA).


JUNE- –Continue parallel Coding if coding is in house

Assess intake process and new forms, look at business ops processes, and relook at RCM process as they relate to ICD-10.

Audit ICD-9 and ICD-10 processes and forms

Hospices finalize implementation process of new HIS tool



Confirm all payors, vendors and clearinghouses are ready to process ICD-10 claims

Submit final test submission of claims to clearinghouse portal.

Finalize and then implement ICD-10 Corporate wide Compliance Plan.

Implementation of the Hospice Item Set (HIS)

OASIS C1 Grouper to be announced

Prepare for the 40-50% increase in coders needed to code ICD-10 if coding in house



Complete Coding Compliance Plan and present to personnel

For 60 day episodes, RAPS beginning August 3, 2014 will have ICD-9 CM codes, but the final claim, if the episode ends on or after 10/1/2014 will have ICD-10 CM codes.

Now, might be the best time to take a vacation.



You have prepared for ICD-10

You have prepared for OASIS C1

Take a final walk through processes

Final orientation of 40-50% increase in new coders hired to handle ICD-10 if you chose to code in house.



ICD-10 CM is in effect!

OASIS C1 is now in effect

Wage index for Hospice becomes effective

10/16 Deadline for submitting Q2 2014 data for HH-CAHPS



Resubmit rejected claims due to incorrect ICD-10 coding

Re-evaluate processes

Final 2014 PPS Rule due from CMS

Case Mix Grouper released


That review takes us to Thanksgiving and the holidays. We have survived the year!

Preparing for ICD-10: More than Review Sessions for the Coders

Monday, October 21st, 2013

CMS has already identified the expectation of at least a 10% claim rejection due to incorrect codes or codes lacking in specificity.  Besides increased claim rejections, payors are predicting increased delays in processing care authorizations, slowing cash flow, and coding backlogs.

To guard against being one or several of those statistics, home health and hospice agencies must prepare now.  Agencies must plan for education and training of coders, billers, and managers, updating software and hardware, updating forms, processes, policies and procedures, and related consulting costs.

Leaders must prepare for a decline in clinical and coding productivity as well as the need for data conversion and design of new tools and resources. On the positive side, conversion to ICD-10-CM affords the agency leaders the opportunity  to conduct a comprehensive review of agency operations and to determine if contracting with an outside third party Coding agency is the best way to handle much of ICD-10-CM.

Leaders must look at who and what will be impacted at their agency and devise a strong plan.  Timelines for assessing gaps, devising interventions and tools as well as testing those items must be included in the plan.

Clinical leaders must look at what documentation may need to be expanded. What forms and processes will be impacted?  IT managers must look at system readiness not just for 5010, but for financial and clinical data conversion, reformatting of reports, as well as compliance risks.  Billing managers must look at any claims processing changes and reconciliation processes and reports. They must look at ICD-10 implementation dates, payor readiness and the ability to run dual systems for ICD-9-CM for care delivered prior to 10/1/2014 and ICD-10-CM for care delivered on and after 10/1/2014.

CFOs must look at a budget for training, education, updating of software, clinical and coding learning curves and time additions for new coding and process implementation.  They must plan for potential cash flow delays if their claims are rejected.

CEOs and COOs must look to additional personnel needs due to increased time needed for learning and for ongoing coding requirements. They must look at training and education of, not only employees, but of subcontractors and contractors as well. They should evaluate contracting with third party coding firms and determine advantages and any disadvantages. With all of the other changes impacting the industry, many agencies are deciding coding should be completed by third party experts, such as Select Data.  Leaders must appoint managers for ICD-10-CM implementation, HIPAA HITECH risk management, preparation for the new Chronic Care Management models; ACOs, Patient Centered Medical Homes, Transitional Care programs and all the program outcomes anticipated. The leaders must evaluate their internal expertise and determine if external consulting or service delivery, is needed.


Let’s look at one of the first groups to be considered for education: the intake team.

Does the intake process need to be expanded? Do the forms need to be expanded to accommodate the additional documentation required for the increased specificity necessary for ICD-10.  What are the most common diagnoses treated by the agency? What will be the needed documentation to justify assignment of those codes?

Does the team have a working knowledge of ICD-10-PCS so they may identify procedures performed in the acute care setting?

Who will be responsible for modifying forms and tools?  Does your process and/or software system require the intake team to assign a preliminary primary diagnosis? Who will be responsible for ICD-10 education for this team?


Direct Care Providers, whether they are employees or contractors should have an overview of OASIS C1 and the changes implemented.  They should have a review, if necessary, as to the meaning of the questions, the timeframes to be considered, and the resulting documentation necessary. In addition, they should have a thorough understanding of the general differences between ICD-9-CM and ICD-10-CM and the detailed requirements of ICD-10-CM.  The coding specificity depends on very detailed documentation. Presently, clinical documentation is under scrutiny by auditors. I am amazed when we perform audits for agencies throughout the country, the level of insufficient documentation present and the exposure of an agency if a RAC audit would occur.

At the very least, agencies should identify the top 20 diagnoses utilized at their firm, and identify the new codes, including the combination codes identified with each. Examples of combination codes include:

E08.21 Diabetes due to underlying condition with diabetic neuropathy
E08.341 DM due to underlying condition with severe non-proliferative diabetic retinopathy with macular edema
E08.22 DM due to an underlying condition with diabetic chronic kidney disease
E09.52  Drug/chemically induced DM with diabetic peripheral angiopathy with gangrene
E11.41 Type 2 DM with mononeuropathy

Review the agency assessment  for content detail  capability:

Does the assessment have laterality?
Does it have the depth of content and detail needed to support the potential diagnoses?
If the assessment was thoroughly completed, would it withstand a RAC auditor’s review?
What forms and tools will require modification? What about the careplan?
Should the Visit/Progress note be modified?
Are these notes outcomes driven?
What about Patient Teaching Tools?  Do they encourage patient self- engagement?
If the clinicians already have difficulty adequately documenting conditions, do you have a strategy for change?


Because the new ICD-10-CM code set is expected to cause a 10% rejection of all claims due to coding error and lack of specificity, the billing team should have a strong process in place to handle claim rejections and denials.

Does your Clinical team routinely audit records?
Does your Coding team have outside audits performed on their work product so you are reassured of the accuracy of the coding?Does your billing team have internal audits performed to evaluate process effectiveness, as well as claim accuracy and timely billing?

Obviously, order centric and coding centric processes should be in place to reduce denials. Assignment of codes must be predicated on specific documentation that has been verified by the coding specialists as a part of the client record.


ICD-10-CM has meant a HIPAA Version 5010 transition prerequisite.  It also means clinical and billing software system updates and processes. The impact to IT goes beyond the mere increase from 5 to 7 characters. It also means that the IT must be prepared for a dual system to be in place to handle ICD-9-CM claims for Starts of Care prior to 10/1/2014 and for care initiated on or after 10/1/2014.

Is your software vendor evaluating their integrated OASIS assessment tool to be certain it meets all the specificity requirements necessitated by ICD-10-CM?

From the simplest of needs: does it have laterality that allows for designation of both primary diabetic types, the three secondary types, and provide detail choices to support all types and conditions?


Have you contacted the payors for their planned readiness to test their system?
Have you communicated with your Clearinghouse?  We work with Emdeon and they have a test environment available to accept the new codes on claims. This environment will let us know rejection and acceptance of claims for specific payors.

CMS stated the new Grouper will be available in February, 2014. Then we will have a better understanding of the HHRG and case mix diagnoses of the future. One hundred seventy (170) casemix diagnoses have been proposed for removal thus far.


Well trained coding specialists improve your ability to drop high level clean claims coded to the highest level of specificity.  Well versed coding specialists can improve compliance, aid in OASIS accuracy, and improve likelihood that paid revenue remains retained revenue.

Agencies are finding that the specificity requirements of ICD-10-CM are necessitating updated courses in Anatomy, Physiology, Pathophysiology, Diagnostics, Pharmacology totaling around 50 hours. Agencies know the coding specialists will also need specific training of ICD-10-CM and should allow around 20+ hours.

Additionally, agencies must allow time for coding practice and parallel coding so the specialists see the differences and can practice for the future. Select Data will begin this process Q1 2014.


A smooth transition to ICD-10-CM with clean claims means effective planning. Your ICD-10-CM Project Team (consisting of members from all departments) should have by now completed the gap analysis for all departments, have started the coder training updates, and have  sent out the first letters to the payors requesting their ICD-10-CM status. You have or will soon have identified processes, tools, and forms impacted by ICD-10-CM and refined your project plan.

Operations should be developing the needed Operational solutions, planning, and preparing for the ongoing training for all departments. Next comes the specific strategies for implementation.

Are you on schedule? We have less than a year. Education and documentation excellence is critical.

Your cash flow and then retention of dollars derived could ultimately depend upon the clinical documentation and the quality of education and overall preparation for this major undertaking.

Home Health Providers Should be Aware of New Updates

Monday, July 30th, 2012

New Shared Saving Program FAQs Posted to the CMS Website

CMS has posted new Medicare Shared Savings Program Frequently Asked Questions (FAQs) to the CMS Shared Savings Program website. Answers to questions from industry stakeholders have necessitated that the FAQs be updated to provide additional guidance to all Medicare Shared Savings Program applicants under 42 CFR part 425 related to mergers and acquisitions. The new FAQs also cover the following topic categories:  Accountable Care Organization (ACO) Participant List, Form CMS-588 Electronic Funds Transfer, and Governing Body. To learn more about the Shared Saving Program, please visit

Healthcare can only achieve long-term success through strategic alignment between hospitals and their physicians.

CMS and Industry Conferences everywhere are talking ACOs and Care Transition Models.  Explore new hospital and physician integration models online at the CMS website. Learn all you can about ACOs, Guided Care Models, Patient Centered Medical Models, and Care Transitions as home health is changing and you may need to change also.

HHS Announces 89 New Accountable Care Organizations

Just a month ago the numbers were 31 ACOs and 1.1M  beneficiaries. Now CMS reports 2.4 million people with Medicare are to receive better, more coordinated care through 89 new ACOs.

On July 9, HHS Secretary Kathleen Sebelius announced that as of July 1, 2012 there were 89 new Accountable Care Organizations (ACOs) serving 1.2 million people with Medicare in 40 states and Washington, D.C. ACOs are organizations formed by groups of doctors and other health care providers that formally agree to work together to coordinate care for people in need covered by Medicare.

The Medicare Shared Savings Program (MSSP), and other initiatives related to ACOs, is made possible by the Affordable Care Act (ACA).  The 89 ACOs announced on July 9 bring the total number of organizations participating in Medicare shared savings initiatives to 54. In all, as of July 1, more than 2.4 million beneficiaries are receiving care from providers participating in Medicare shared savings initiatives.

To ensure that savings are achieved through improving care coordination and providing care that is appropriate, safe, and timely, an ACO must meet quality standards. (See June/July Select Data ezines as to ACO requirements). For 2012, CMS has established 33 quality measures relating to care coordination and patient safety, appropriate use of preventive health services, improved care for at-risk populations, and patient and caregiver experience of care.


Beginning this year, new ACO applications will be accepted annually. The application period for organizations that wish to participate in the MSSP beginning in January 2013 is from August 1 through September 6, 2012.


More Than 16 Million People With Medicare Get Free Preventive Services in 2012

Attributed to the Affordable Care Act, additional preventive services at no cost to beneficiaries.

Prior to 2011, people with Medicare faced cost-sharing for many preventive benefits such as cancer screenings. Through the Affordable Care Act, many preventive benefits are offered free of charge to beneficiaries, with no deductible or co-pay, because, it is believed, cost has been a factor. Now offered at no cost for seniors are several prevention screenings.

The law also added an important new service for people with Medicare — an Annual Wellness Visit with the doctor of their choice— at no cost to beneficiaries.

For more information on Medicare-covered preventive services, visit

The healthcare industry is rapidly changing. Agencies must be ready to change. Are you?

The Patient Care Medical Model and Guided Care: Home Health Collaboration

Friday, June 1st, 2012


  • As a percentage of GDP, health care expenditures are about 18%. By 2019, the national health care expenditures will be 19.3% and approaching an unsustainable level.
  • CMS states: Innovative approaches to quality healthcare must be found.

New Models of Care are mandated under the Patient Protection and Affordable Care Act (PPACA) as well as naturally occurring.

CMS has identified “Triple Aim” Goals

  1. Better Health for the Population
  2. Better Care for Individuals
  3. Lower Cost through Improvement of Care Delivery

CMS motivates with:

  1. Incentive Programs: With Quality Reporting through approved programs and EHR incentives
  2. Payment Policies: With Accountable Care Organizations and innovative programs such as Patient-Centered Medical Homes and solid Care Transition Programs
  3. Quality Programs: The Programs will truly partner with the patient and Quality Care Organizations

CMS states care presently is usually:

  • Uncoordinated- poor medication management, poor preventive care and overall strategies, unreliable information transfer, who to call for what?
  • Unsupported- lacking standard and known process, unsupported patient activation transfer
  • Unsustainable- no comment needed

Health Care delivery is changing fast. Old Medicare models in home health are being moved aside. Are you ready for Care Transitions, Patient Care Medical Models, and Guided Care?  Should you be a collaborative partner with other healthcare sectors? Are you ready to assume some financial risk in a collaborative venture? There are many new innovative projects underway. Two of those new concepts include the Patent Care Medical Model with Guided Care by the Physician and RN. How would your home health agency participate in this new health care delivery process?

CMS states the Patient Care Medical Model (PCMM) rests on five pillars:

  1. Patient-centered orientation directed toward their unique needs, culture, values, and preferences.
  2. Comprehensive, team-based care that meets the majority of each patient’s physical and mental health needs.
  3. Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community
  4. Superb access to care.
  5. A system approach to quality and safety including Care Management Interventions.

Selecting Care Management Interventions include:

CMS suggests discussing many provider and system interventions

Evidence-based Guidelines and Protocols

Provider Education

Practice-site Improvement

Provider Profiling and Reports

Provider Incentives

Registries and Clinical Information Systems


Electronic Medical Records, Decision Support Reminder System, and Other Electronic Communication Systems

Educational Brochures and Member Letters

In-Person Care Management

Call Center

Self-Management Education

Self-Monitoring Devices

The Patient Care Medical Home (PCMH)

“The PCMH is intended to result in more personalized, coordinated, effective, and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location by:

  • Taking collective responsibility for patient care
  • Providing for the patient’s health care needs; and
  • Arranging for appropriate care with other qualified


The Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare

  • Requires an interdisciplinary team to take responsibility to improve access, continuity, and coordination of care
  • Patients and family members are engaged through education and supporting self-care and disease management
  • The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person.

This program is comprehensive, team based primary care for reducing cost geared toward a collaborative model, easy to implement, capable of providing excellent care to patients with multiple chronic conditions.

Using Guided Care in this Model


  • Specially trained RNs based in the PCMH physician offices.
  • The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions.
  • The nurse and her “back-up” RN partners with the patient for the rest of the patient’s life.

This model was initiated in 2002 by John Hopkins University.


The RN will converse, assess, and create an evidence-based Care Guide (notice they chose “guide” not “plan”).

The Guided Care RN coordinates care with other care providers, HH providers, clinics, and hospitals.

The Guided Care RN educates and supports family and caregivers.

This RN also identifies community services that are most appropriate for this patient and her needs.


Physicians planning Guided Care Can receive:


Free Technical assistance at:

Online courses from John Hopkins Nursing available for RNs,

There are also Physician and family courses

Order the free Implementation Manual:

Guided Care: A New Nurse-Physician Partnership in Chronic Care

There are also free books and material for families.

Guided Care is

A collaborative approach, physician directed-Nurse assisted, that truly works with the patient to achieve education, accomplish goals, and allieve anxiety from lack of continuity

A proven evidence based team approach that includes care planning, care transition, education, and support

Look at Kaiser

Look at Vanguard Medical Associates

Piedmont Community Health Plan


Home Health Agencies Interested in Collaboration


Look for innovative partnerships

Offer same day access and response

Look at creative tools needed; specialized programs.

Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs.

Find consistent communication methods and processes.

Establish proactive, prepared, practice teams.

Be willing to break away from the traditional Medicare model of care.

Consider shared risk.


Home Health Agencies should


Be willing and available of leadership and clinicians to “up-skill.” Be flexible. Be rapid in response.

Be willing to work COLLABORATIVELY.

Agree to have certain clinicians trained in PCMH constructs.

The HH agency should see improvements in goals attained.

The HHCAHPs should reflect the patient satisfaction.


New Innovations and New Types of Care Delivery


Together we can invent and create our way to success.  We can work together for a individualized, sustainable, proud new American Health Care System. Better care is overall less costly care. No matter how we view the new models, they are going to augment and eventually could replace the present model. Your thoughts?