In this session, we explore the alignment of the primary diagnosis, the F2F encounter, and the Plan of Care (POC). We also review common scenarios in which the F2F encounter does not align with the POC and detail strategies agencies can employ for realignment.
- Encounter notes should align with the focus of care and services being provided in the home
- A physician-signed assessment should be used to justify the referral to home health and support
the need for skilled services
- Operative Notes and H&Ps do not typically provide a current status of the patient or support their
need for home health
- For documentation from a post-acute facility to be accepted the patient must be directly
admitted to home health from the facility
- Establish a process to identify the appropriate encounter within the EMR to ensure the date goes
on the Plan of Care
- Receive necessary documentation at the time of the referral and indicate in the EMR which
encounter note will be considered the Face-to-Face encounter
- Identify the primary reason for home health once the referral is received. If this is unclear
the referral source should be contacted for additional information.
- Request access to the EMR of referral sources, this allows Intake staff to pull down what they
need, if this cannot be done