Appendix A. Side-By-Side Comparison of a Home Health Plan of Care Form

• Name
• Address
• Date of birth
• Sex
• Start of care date
• Certification period

• HHA name
• HHA address
• HHA telephone number

Diagnoses

• Principal diagnosis, ICD-9-CM code, and date of onset/exacerbation
• Surgical procedure, ICD-9-CM code, and date
• Other pertinent diagnoses, ICD-9-CM codes, and dates of onset/exacerbation

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• Option to communicate specific drug allergies:
  • Penicillin
  • Sulfa
  • Aspirin
  • Codeine
  • Other (specify)
  • No known allergies

• Amputation
• Bowel/bladder
• Contracture
• Hearing
• Paralysis
• Endurance
• Ambulation
• Speech
• Legally blind
• Dyspnea with minimal exertion
• Other

Functional Limitations

SAME, with the addition of:

• Dysphagia
• Option to instruct the home care nurse to:
  • Assess the functional limitations indicated

• Oriented
• Comatose
• Forgetful
• Depressed
• Disoriented
• Lethargic
• Agitated
• Other

SAME

• Poor
• Guarded
• Fair
• Good
• Excellent

SAME

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• Option to communicate specific goals to home care nurse:
  • Patient/caregiver will be knowledgeable about disease; behaviors needed to manage condition; signs and symptoms of complications; prescribed diet; signs and symptoms of an emergency and know appropriate actions.
  • Patient/caregiver will demonstrate proper administration of medication.
  • Patient/caregiver will identify purpose, dose, schedule, adverse effects, and contraindications of prescribed medication.
  • Patient/caregiver will demonstrate treatment as prescribed.
  • Wound will show signs of healing.
  • Patient will report a decrease in pain.
  • Patient will increase participation in ADLs

• Dose
• Frequency
• Route
• Indication of "new" and "change" orders as needed

Discharge Medications

SAME, with the addition of

• Option to instruct the home care nurse to:
  • Assess heart failure medications.
  • Teach/reinforce roles, side-effects, and dosages of medications.
  • Check for medication adherence.

• Option to instruct the home care nurse to:
  • Increase _______ by ______ mg each week until blood pressure is ____/____
  • Increase _______ by ______ mg each week until pulse is ________
  • Notify physician each week with report of vital signs, physical findings, and current medication doses when adjusting medications.

• Option to instruct the home care nurse to:
  • Notify physician for systolic blood pressure <90 or >160
  • Notify physician for diastolic blood pressure >100
  • Notify physician for pulse <55 or >100
  • Notify physician for weight gain greater than _____ lb in ____days
  • Notify physician for weight loss greater than _____ lb in ____ days

Skilled Nursing (amount/frequency/duration included)

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• Option to instruct the home care nurse to:
  • Teach patient to monitor daily weights.
  • At each visit assess: pulse, blood pressure, weight, heart rate and rhythm, lung sounds, and lower extremities for edema and perfusion.
  • Monitor and teach signs and symptoms of worsening heart failure.
  • Educate about low sodium diet.

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• Option to instruct the home care nurse to:
  • Perform home safety assessment.
  • Other (specify).

• Complete bedrest
• Bedrest BRP
• Up as tolerated
• Transfer bed/chair
• Exercise prescribed
• Partial weight bearing
• Independent at home
• Crutches
• Cane
• Wheelchair
• Walker
• No restrictions
• Other (specify)

Activities Permitted

SAME, with the addition of

• Option to communicate/order:
  • No restrictions.
  • Assess need for physical therapy evaluation.
  • Physical therapy evaluation.

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• Option to order:
  • Level 1 mattress
  • Level 2 mattress
  • Hospital bed
  • Wheelchair
  • Hoyer lift
  • Trapeze
  • Suction machine
  • Home oxygen (liters/min)
  • Tub seat
  • Commode
  • Other(specify)

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• Option to instruct the home care nurse to:
  • Assess supplies needed
  • Other (specify)

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• Option to instruct the home care nurse to:
  • Assess nutritional requirements
  • Other (specify)

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• Option to instruct the home care nurse to:
  • Assess need for home health aide.

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• Option to instruct the home care nurse to:
  • Assess need for physical therapy.
• Option to instruct the therapist to provide specific treatments:
  • ADL training
  • Chest physical therapy
  • Coordination/balance activities
  • Establish/upgrade home program
  • Gait training
  • Prosthetic/orthotic training
  • Therapeutic exercises
  • Transfer training
  • Other specify)
• Option to instruct the therapist to provide specific modalities (locations and parameters included):
  • Cryotherapy
  • Moist heat
  • TENS
  • Other (specify)

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• Option to instruct the home care nurse to:
  • Assess need for occupational therapy
  • Option to instruct the therapist to provide specific treatments:
  • ADL training
  • Cognitive training
  • Establish/upgrade home program
  • Fine motor coordination
  • Functional transfer training
  • Orthotic/splinting
  • Therapeutic exercises
  • Visual perceptual training
  • Other (specify)

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• Option to instruct the home care nurse to:
  • Assess need for speech therapy
• Option to instruct the therapist to provide specific treatments:
  • Aphasia treatment
  • Cognitive communicative treatment
  • Dysphagia treatment
  • Establish/upgrade home program
  • Non-verbal communication training
  • Speech/voice disorders treatment
  • Other (specify)

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• Option to instruct the home care nurse to:
  • Assess need for medical social worker

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• Option to instruct the home care nurse to:
  • Assess need for audiologist

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• Option to communicate expectations for plans for care after discharge:
  • Assisted living
  • Care to be provided by family/friends
  • Certified agency
  • Home attendant service
  • Hospice
  • Long-term home health program
  • Nursing home
  • Self-care
  • Other(specify)

• Option to instruct the home care nurse to:
  • Provide and/or instruct catheter insertion
• Option to communicate details for catheter insertion:
  • Straight for:
    • Residual
    • Voiding
    • Specimen
    • Type (clean, sterile)
  • Foley:
    • Suprapubic
    • Urethral
    • For (retention, incontinence, initial insertion)
    • Next change date
    • Lumen size
    • Balloon size
    • Frequency

• Option to instruct the home care nurse to:
  • Provide and/or instruct external catheter application (QD & PRN)
  • Provide and/or instruct catheter
  • Irrigation
• Option to communicate details for catheter irrigation:
  • Foley
  • Nephrostomy
  • Solution (NS, other, amount)
  • Frequency
• Option to instruct the home care nurse to:
  • Provide and/or instruct catheter care (Foley QD & PRN, external QD & PRN)

Diabetes Care

• Option to instruct the home care nurse to:
  • Provide and/or instruct foot/leg care
  • Provide and/or instruct injury/infection prevention
  • Provide and/or instruct signs and symptoms of hypo/hyperglycemia
  • Provide and/or instruct insulin administration
  • Provide and/or instruct insulin prefill

  • Provide and/or instruct blood glucose monitoring-includes

    - Fingerstick frequency: ___ /day
    - Patient' normal range: __ to __
    - Contact physician if glucose: > ___ or < ___

Central Line Catheter

• Option to instruct the home care nurse to:
  • Flush with NS, followed by heparin 1,000 units weekly.

Wound Care
Orders for up to 3 wounds (location included)

• Option to communicate wound type:
  • Surgical (open, closed)
  • Neuropathic ulcer
  • Pressure ulcer stage (1-4, unable to stage)
  • Venous stasis ulcer
  • Arterial ulcer
  • Arterial/venous stasis mix
  • Burn/radiation burn
  • Traumatic
  • Other wound/lesion etiology (cancerous, dermatological, inflammatory, lymphatic, sickle cell/thalassemia, unknown)
• Option to instruct the home care nurse to:
  • Step 1: cleanse, irrigate, soak for ___ minutes
  • Solution 1: NS, other
  • Step 2: cleanse, irrigate, soak for ___ minutes
  • Solution 2: NS, other
• Option to communicate details for packing:
  • Alginate
  • Foam
  • Gauze (dry)
  • Gauze hypertonic sodium impregnated/Curasalt™
  • Hydrocolloid paste
  • Hydrogel impregnated gauze
  • Hydrogel liquid/amorphous
  • Hydrogel solid sheet/strands
  • Packing strips
  • Wet to damp NS
  • Wet to dry NS
  • Other (specify)
• Option to communicate details for primary dressing:
  • Alginate
  • Foam
  • Gauze (dry)
  • Gauze hypertonic sodium impregnated/Curasalt™
  • Hydrocolloid paste
  • Hydrogel impregnated gauze
  • Hydrogel liquid/amorphous
  • Hydrogel solid sheet/strands
  • Transparent
  • Wet to damp NS
  • Wet to dry NS
  • Other (specify)
• Option to communicate details for secondary dressing:
  • Foam
  • Gauze (dry)
  • Gauze wrap
  • Hydrocolloid
  • Transparent
  • Other (specify)
• Option to communicate details for venous stasis/lymphedema compression orders:
  • Unna Boot/Viscopaste* and Coban™
  • Multiple-layered bandage/Profore™
  • ACE® bandage
  • Compression stockings
  • Other (specify)