3 Best Practices for a Collaborative Plan of Care

February 22, 2020

Here at Medalogix, it’s no secret we believe in the power of interdisciplinary collaboration. In a recent post, we even proclaimed how timely collaboration can be positively magic, especially when driven by Medalogix Care.

Just to recap: Based on data science rooted in historical data and known outcomes, Medalogix Care analyzes the start of care and resumption of care OASIS data to recommend the optimal number of visits needed for every unique patient to achieve a discharge outcome to community. Yep, the algorithm is rooted in clinical outcomes. It’s about what’s best for the patient. Plain and simple.


Ah, but there’s one catch. Medalogix Care is based on analysis of the OASIS assessment, and therefore requires a timely, accurate, and yes, collaborative OASIS and plan of care development to achieve the magic. That’s right—Care can’t do its thing without you first doing yours.

Let’s Look at the Best Practices for a Collaborative Plan of Care:

1. Lay the Foundation with an Accurate Referral

A solid referral is the critical first step to facilitate a well-informed and collaborative start of care process. We know your intake team is already focusing on PDGM-related coding changes and are painfully aware that questionable encounters will sink you. But getting the most accurate, specific, and valid diagnoses codes right on the frontend has other crucial benefits. If you know the diagnoses, and they align with the face-to-face visit supporting documentation, the admitting clinician will know what to expect and will save time. Knowing the diagnoses codes will also help you better identify potential therapy needs so orders can be obtained at the point of referral, not during or after the start of a care visit.

2. Require Interdisciplinary Collaboration BEFORE Finalizing the OASIS and Plan of Care

Ask yourself the following questions:

      • Do you have an expectation or communication process between nurses and therapists to collaborate on their assessments once they’ve each seen the patient individually?
      • Do your clinical managers have a process to review therapy evaluations to ensure they align with the RN start of care OASIS?
      • Are your admitting clinicians asked to relook their OASIS responses to address inconsistencies and contradictions after subsequent discipline evaluations?

If you haven’t answered yes to all of these questions, you have some work to do! Truth is, interdisciplinary communication should always happen prior to OASIS completion. If you’re not collaborating, your OASIS may not accurately reflect the patient status.

How can you promote collaboration? The obvious answer is to schedule the RN and therapist to have at least some time in the home for the start of care comprehensive assessment – together. Since schedules won’t always allow for overlapping visits, implement a policy to ensure that the RN and therapist are having a telephone conversation to align. The clinical manager is a natural resource to facilitate this conversation, centering it on need for services, relevant diagnoses and OASIS scrubbing.

Because the accuracy of Medalogix Care is dependent on OASIS accuracy, our implementation best practices promote collaboration. Once the OASIS is accurate, clinicians use the patient-specific Medalogix Care visit recommendation as a basis on which to begin collaboration and drive subsequent physician communication to support the home health clinician recommended plan of care. Are we saying this collaboration can help with physician communication? Of course, read on…

3. Capitalize on Collaboration with Physician Communication

Now that all of this magical collaboration has occurred among the home health team, it’s time to communicate with the physician. It goes without saying, but we’ll emphasize for clarity: Medalogix Care and the interdisciplinary collaboration it fosters should in no way replace the requirement that home health services must be furnished in accordance with physician orders. Now it’s time to take advantage of unified assessment findings to convey those patient needs that were observed in the home but may not have been reflected in the initial referral orders. State your case to the physician clearly and concisely in order to support your plan of care recommendations.

Just three basic concepts—it’s really that simple.

However, we know implementing collaboration on any team can be a little more challenging. So be on the lookout for a follow-up post on how you can apply the tried and true SBAR (Situation, Background, Assessment, Recommendation) method as a strategy to operationalize collaboration at your own organization.

Learn More about Medalogix Care

If you’re already using Medalogix Care, we’d love to hear from you. If you’re not and would like to take your organization’s plan of care collaboration even deeper, we’d really love to hear from you.

Don’t wait—Schedule a demo today!

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