Home Care communication with family physician.

Coordination of Care.

Physician and Home Care Agency.

A patient has a primary physician and is currently receiving home care services. OASIS assessments are completed by home care agency clinical staff at start of care, every 60 days (follow-up) and on termination of home care services. These assessments contain the following functional status information:

sensory status

integumentary status

respiratory status

elimination status

neuro/emotional status

ADL/IADL

patient management of medications and equipment

The home care agency encodes the functional status information (along with other information on the patient) into a CCD. This CCD is sent electronically to the physician's office and processed by the clinical management system used at the physician's office. The functional status information is available to be viewed by the physician.

Based on responses to the OASIS item for Depressive Feelings (M0590), the home care RN suspects the patient is depressed. He uses the Geriatric Depression Scale (GDS) to obtain more information on the patient's depressive feelings and determines that the patient is moderately depressed. The physician did not mention that the patient was depressed when making the initial referral, or on subsequent phone calls with home health agency staff. The agency RN contacts the physician by telephone to discuss the findings from the GDS. The physician requests a copy of the GDS, which is sent electronically. The physician is able to use the GDS findings to determine possible treatment options for the patient.

Another use case could be a patient that is starting to become cognitively impaired (this would be recorded in thje latest OASIS). This information can be sent to the physician's office system and inform the physician that when giving treatment instructions to the patient that these instructions be written and that possibly a caregiver should be present.