Coordination of Care

Towards the end of the Provision of Services (PS) standards, almost to the end of the section, is the very simple accreditation standard PS 9: The Coordination of Care.  The standard, in very simple, straightforward language, reads:

The organization documents the coordination of care between all those involved in the delivery of services or equipment/devices to the client. The organization documents communication with the client and between providers in a standardized manner within the client medical record.

Compliance with this standard can make or break an organization.  Failing to comply with the standard leads to an inefficient healthcare delivery system and programs that lack coordination tend to expend more time, effort, energy, and money to run than programs that are coordinated.  Coordination is important within the various departments of your organization and also with outside vendors, referral sources, and others involved in a given client’s care.   Lack of coordination shows—the surveyor will most likely notice as will your clients, referral sources, and other organizations involved in care. Let’s explore how care can and should be coordinated within an organization.

Effective coordination starts when a referral source calls a referral into your organization.  These referrals set the wheels in motion for a new client to be admitted to service at your organization.  Consider the example of a new oxygen client referral coming from a hospital discharge planner:

1. Financial responsibilities are considered and if an insurance or other third-party payer is going to be involved, the billing process starts.  Coverage and deductibles must be verified and that information must be communicated to the new client or his caregivers (or in some cases, the referral source).
2. Equipment technicians need to be notified and need to pull the appropriate equipment and supplies for the new client. This equipment is customized for the client, depending on their liter flow needs, whether or not they need a portable system, etc. 
3. Many organizations utilize respiratory therapists for clinical functions or new client teaching. The RT may be an employee, or he or she may be an outside contracted service.  Regardless, that person will need to be “in the loop” regarding the new client and the timing of the delivery/set up.  In some cases, oxygen may need to be titrated based on a pulse oximetry test.  This is becoming more and more common with the advent of conserver devices including portable concentrators and tanks with conserver regulators. 
4. Meanwhile, customer service, or someone within the organization will need to coordinate delivery schedules with hospital discharge and the date/time the client is coming home. In some cases, they will need a portable delivered to the hospital to come home with. 
5. Once the client is safely home, instructed on the new equipment, and stabilized, the referral source may need a report to assure them their patient is taken care of and has everything they need. Marketing personnel will need to be notified so they can acknowledge the referral.  At some organizations, they may be part of the actual discharge and care, but at other places, they simply need informed, so they are aware their efforts have paid off. 
6. The care plan is established with input from delivery and clinical staff and anyone else involved in the teaching of this new client. The care plan should also be reflective of any outside organizations such as nursing agencies, hospices, or other coordinated treatment providers. 

Any of the above “departments” can break the chain of communication and thus disrupt coordination.  The fact that a chain is only as strong as its weakest link has never been truer!

The good news is that this is a relatively easy standard to comply with!  First and foremost, it requires common sense and good communication.  Corporate culture should support and encourage open and thorough communication between the various departments.  Make sure each department is communicating in some standardized format.  Whether you are using electronic recordkeeping software or paper medical record files, there should be a standardized methodology to how the various departments communicate with each other.  This can be done on progress notes, plan of care updates, or something as simple as a communication log. 

Outside entities such as home health nurses, contract respiratory therapists, hospice personnel, etc. should be informed of any information that is pertinent to their care plan.  And they should communicate to your organization when their care has an impact on the care you are providing your client.  This has become an increasingly difficult feat to accomplish with different organizations winning bids for different equipment and services.  Care coordination can be challenging when one organization provides oxygen and another one provides CPAP or non-invasive ventilators for the same client.  Coordination may include coordinating a visit to the client’s home at the same time as the other organization to ensure truly coordinated, safe, effective equipment set up. 

Watch for the following “outside” entities which should all be included to one degree or another in the coordination of care of your client:

• Contract RT practitioners who provide clinical functions and/or equipment teaching.
• Home health nursing when the nursing care is effected by the provision of DMEPOS services. (Consider providing in service education for nursing staff if they are going to be caring for your client and possibly troubleshooting your organization’s equipment).
• Other therapies such as physical, occupational, or speech language pathologists—particularly if their home visit schedule impacts when your organization should be performing your home visits.
• Hospice organizations. Hospice contracts vary widely case by case.  Some do most of the equipment teaching and troubleshooting; others will be relying on your staff.   Both scenarios are acceptable, but make sure SOMEBODY has educated the client and caregivers. 
• Other DME organizations if you have overlapping equipment such as PAP and oxygen provided by two different organizations.
• Certainly, the referral source is an entity that needs to be kept in the loop; particularly with any changes to prescribed therapy or services.

Absent good care coordination, the client experiences confusing customer service and education on the product or services that may be lacking.  With solid care coordination, the client experience is completely different introduction to their product or service that sets them up for a thorough understanding of the plan of care and better compliance rates with the prescribed therapy.  Of course, this leads to excellent customer service and happy referral sources AND customer clients!

“Alone we can do so little; together we can do so much” -----Helen Keller.