1. Krafft, Cindy PT, MS

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Imagine a typical home healthcare case conference with clinicians from various disciplines around the table. The patient is presented to the group, as "Mr. Smith, a 79-year-old with heart failure and diabetes admitted for skilled nursing, physical therapy and home health aide." The nurse provides her update on the admission visit and her plan of care set at two times a week for 4 weeks, then once a week for 4 weeks to work on heart failure (HF) education and medication management. The physical therapist reports a plan of three times a week for 3 weeks focused on gait and transfer training and therapeutic exercises. The nurse then states that the home healthcare aide will be going three times a week for 9 weeks to assist with bathing and dressing. Everyone nods in agreement and the agenda moves to the next patient.


Ask yourself the following questions:


* Do these "updates" really represent coordinated care?


* Do you know what the patient's key issues are?


* What is the team working on together? Are they on the same page?


* Are the self-care issues being addressed with a long-term vision as a short-term fix?



In light of the proposed changes to the Medicare Conditions of Participation, the home healthcare industry needs to reevaluate the idea of interprofessional care management. The removal of what appears to be separate expectations for nursing and therapy to a model driven by "skilled services" is more than a semantic one. This new vision impacts many of the fundamental ideas and practices seen in many home healthcare agencies:


1. The nurse is the "case manager" responsible for the patient care plan.


2. Therapy is included about 50% of the time specifically for patients deemed able to improve.


3. Giving other disciplines updates is how care coordination is demonstrated.



As we enter the future of home healthcare, let's take each one of these and consider different options.


No one is downplaying the importance of the nurse but the idea that one discipline bears the responsibility of integrated care is not as effective as holding team members as equal partners. The current assignment by discipline does not reflect the comprehensive needs of individual patients and does not facilitate collaborative care.

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Limited understanding of the Jimmo versus Sebelius decision regarding the improvement standard (Centers for Medicare and Medicaid Services, 2013) has resulted in underutilization of therapy services in home care. Skilled therapy is not defined only by the ability to improve the patient's situation. Stabilization of function and prevention of decline that requires the specific training and expertise of a therapist is a valuable use of these services.

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The management of HF and reducing rehospitalization is an often-discussed topic in home healthcare agencies. Considerable resources have been expended in this specific area. A fundamental component of the care plan for HF patients is the importance of weighing daily. But has the functional ability to safely complete this task at the designated time of day been addressed? Is it fair to say that this task has become an "activity of daily living" for this population? As such, why is it not routinely addressed from that perspective and incorporated into a therapy plan of care? This is one example of how the current "update" model may not be sufficient in a collaborative care model.

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The future is bright for home healthcare agencies that know how to manage the ever-increasing and complicated Medicare population with limited resources. Education that addresses interprofessional care is an integral part of success.


Nurses Take on New and Expanded Roles in Healthcare

Massachusetts General Hospital (MGH) is known for medical innovations such as the first public demonstration of surgical anesthesia and the first replantation of a severed arm. Today, the venerable Boston hospital is testing out another innovation, but this time it's in the field of nursing. When a patient arrives at MGH now, he or she is assigned an attending registered nurse (ARN) for the duration of the hospital stay and after discharge. The ARN builds a relationship with the patient and his or her caregivers, and ensures that all members of the patient's healthcare team follow a shared care plan. Unlike other RNs, ARNs are designed to promote continuity of care, ideally with a 5-day, 8-hour work schedule. "The role is designed to be a constant throughout the patient experience," says Jeffrey Adams, PhD, RN, director of the Center for Innovations in Care Delivery at MGH and a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2014-2017). "The person the patient sees every day is available ahead of admissions and post-discharge. This is different than anything we've seen before. We evaluate this work closely and we know ARNs have significantly contributed to improved quality and patient satisfaction." The ARN is just one of the many new roles for nurses in a changing healthcare system. These new roles are empowering nurses to play a greater role in improving patient experiences and population health and lowering costs. Nurses in new roles are doing that by reducing unnecessary and costly hospital readmissions and preventable medical errors, providing more affordable, more convenient, and more patient-centered primary care in community-based settings, and more. For the full story visit:

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Centers for Medicare and Medicaid Services. (2013). Jimmo v Sebelius settlement agreement fact sheet. Retrieved from[Context Link]