Losing Sleep Over 2018 CoPs?

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Rhonda Perrin Oaks, RN, CHP By Rhonda Perrin Oakes, RN, CHPN 
Regulatory Analyst, Change Healthcare
Home Health CoPs Tips

Many home health executives are losing sleep over the Conditions of Participation (CoPs) that took effect in mid-January. There’s good reason for this—they’re designed to create a fundamental shift in how care services are planned, executed, documented and evaluated.

To bring home health organizations in line with CMS’s goals for providing better care at lower cost, the 2018 CoPs add to the elements required for the plan of care, mandate an interdisciplinary approach to care, create a new role (clinical manager) and place a greater emphasis on infection control and emergency preparedness.

Here are the required elements of the plan of care:

  1. All pertinent diagnoses
  2. Patient’s mental, psychosocial and cognitive status
  3. Types of services, supplies and equipment required
  4. Frequency and duration of visits to be made
  5. Prognosis
  6. Rehabilitation potential
  7. Functional limitations
  8. Activities permitted
  9. Nutritional requirements
  10. All medications and treatments
  11. Safety measures to protect against injury
  12. Description of patient’s risk for ED visits and hospital readmission and all necessary interventions to address the underlying risk factors
  13. Patient and caregiver education and training to facilitate timely discharge
  14. Patient-specific interventions and education, measurable outcomes and goals identified by the provider and the patient
  15. Information related to any advanced directives
  16. Any additional items the home care organization or physician chooses to include
  17. All patient care orders, including verbal orders

An interdisciplinary approach

In addition, the 2018 CoPs stress an interdisciplinary approach to care, meaning organizations must eliminate existing siloes (e.g., between therapy and nursing) to the point where they’re both providing coordinated care and documenting how this is being achieved. Patient and caregiver engagement initiatives and healthcare professional education agree on the following: Patient-centered care requires the care team to recognize and incorporate patient/caregiver preferences, strengths, limitations, and the patient/caregivers desired level of participation in the care to be delivered. 1, 2, 3

The three main elements of an interdisciplinary care plan are problems, goals, and interventions.

  1. Clinical findings/observations validate the problem(s) that require medically necessary care to be delivered.
  2. Patient centered goals are shared by all disciplines, established cooperatively with patient/caregiver and documented as such. The goals must have target dates that are tracked and updated throughout the episode to show progress, and facilitate timely discharge. Note that CMS doesn’t demand goal accomplishment within a certain number of days, but if a clinician specifies a target date and misses it without adjusting the goal and the plan, a surveyor is likely to take issue with this. Each patient encounter should be reflected as a snapshot of the patient’s journey through the episode of care pertaining to the care being delivered.
  3. Once the desired goals are established, each interdisciplinary team member involved contributes their expertise as interventions. Interventions are part of the care planning process occurring at the level of engagement desired by the patient/caregiver. The interdisciplinary team will recommend products, processes, procedures and the context in which the proposed care will be delivered to achieve the desired goals.
    – Note that interventions are not a clinician task list. The interventions are very specific to the required knowledge, skills, and/or behaviors that will be essential in achieving the desired goal.

    1. Outcomes in patient-centered care are the specific targeted agency objectives that are achieved simultaneously when the patient achieves their desired goals. In some instances, the outcome and desired goal may be synonymous.  In other cases, depending on patient participation, the patient-desired goals will be more granular.  An example is the patient-desired goal, “Safely walk to my kitchen” will correlate to the more granular therapy goals and the overarching agency outcome to help the patient achieve “Improvement in Ambulation-Locomotion.”

Where to focus efforts

We’ve been working with a customer panel for more than six months to discuss the CoP changes and the application and business process changes needed to support them. In many cases, our discussions revolved around using existing functionality within Homecare Advisor™ to document to the CoP’s. As we identified updates needed to existing functionality, we released the updates in several waves last year and will continue to refine as our customers operationalize the new CoP’s and determine tweaks that could help improve their documentation.

These areas seem to be the ones that our customers are focusing most of their internal training efforts:

  1. Use of the care planning process to capture participation in goal establishment and progress towards goal(s)
  2. Patients/caregivers preferences relevant to aspects of their HH Aide care/tasks and include in Aide plan of care
  3. Analysis of goals and/or interventions and if adjustments are indicated.
  4. Better tracking of goals/outcomes
  5. Emergency preparedness and the ability to identify high risk patients quickly for emergency/disaster scenarios.
  6. Advance directives
  7. Electronic storage of advance directive documents in the patient record
  8. Capture of the patient-rights signature electronically
  9. Ability to include an intervention addressing ED/readmission risk in the discipline-specific care plans
  10. Ability to individualize the discharge summary and the transfer summary to meet the patient-specific items the agency desires to include.

Finally, as in everything, the human factor plays a role. In addition to using tools to better plan and document, clinicians must make interventions specific to patient/caregiver’s needs and collaborate with other team members. Ultimately, the documentation tells the story of the patient’s collaborated, coordinated care. The end of the story will reflect the patient’s transition and the care continuum that will begin the next chapter as applicable.

The information provided on this Change Healthcare site is provided to you for informational purposes only. The materials are general in nature, are not offered to you as advice on a particular matter, and should not be relied on as such. Use of this web site does not constitute a legal contract or consulting relationship between Change Healthcare and you.


  1. Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies, 2017
  2. CMS Person and Family Engagement Strategy, retrieved 10/2017 from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Person-and-Family-Engagement.html
  3. Hughes, R., (May 31, 2011) “Overview and Summary: Patient-Centered Care: Challenges and Rewards” OJIN: The Online Journal of Issues in Nursing 16, No. 2, Overview and Summary

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