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

Development of Electronic Transition Tools for Home Health Care

Note: Regulations allow for the plan of care to be in any format, but it must include all of the items of a traditional CMS-485. This side-by-side comparison reflects those constraints
Traditional CMS-485Revised CMS-485
Demographics/Patient Information
  • Name
  • Address
  • Date of birth
  • Sex
  • Start of care date
  • Certification period
SAME
Provider Information
  • HHA name
  • HHA address
  • HHA telephone number
SAME
Diagnoses and Goals

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
Diagnosis
SAME
Allergies-medication and other
Space for free text
Allergies-medications and other
  • Option to communicate specific drug allergies:
    • Penicillin
    • Sulfa
    • Aspirin
    • Codeine
    • Other (specify)
    • No known allergies
Functional Limitations
  • 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
Mental Status
  • Oriented
  • Comatose
  • Forgetful
  • Depressed
  • Disoriented
  • Lethargic
  • Agitated
  • Other
Mental Status
SAME
Prognosis
  • Poor
  • Guarded
  • Fair
  • Good
  • Excellent
Prognosis
SAME
Goals
Space for free text
Goals
  • 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
Orders (Heart Failure Specific on Revised Form)
Discharge Medications
  • 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.
Medication Adjustment
  • 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.
Physician Notification
  • 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)

Space for free text

Skilled Nursing (amount/frequency/ duration included)
  • 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.
Safety Measures
Space for free text
Safety Measures
  • Option to instruct the home care nurse to:
    • Perform home safety assessment.
    • Other (specify).
Activities Permitted
  • 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.
Durable Medical Equipment
Space for free text
Durable Medical Equipment
  • 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)
Supplies
Space for free text
Supplies
  • Option to instruct the home care nurse to:
    • Assess supplies needed
    • Other (specify)
Nutritional Requirements
Space for free text
Nutritional Requirements
  • Option to instruct the home care nurse to:
    • Assess nutritional requirements
    • Other (specify)
Orders for Other Discipline and Treatments (amount/frequency/duration included for each
Home Health Aide
Space for free text
Home Health Aide
  • Option to instruct the home care nurse to:
    • Assess need for home health aide.
Physical Therapy
Space for free text
Physical Therapy
  • 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)
Occupational Therapy
Space for free text
Occupational Therapy
  • 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)
Speech Therapy
Space for free text
Speech Therapy
  • 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)
Social Work
Space for free text
Social Work
  • Option to instruct the home care nurse to:
    • Assess need for medical social worker
Audiology
Space for free text
Audiology
  • Option to instruct the home care nurse to:
    • Assess need for audiologist
Discharge Plans
Space for free text
  • 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)
Orders for Other Conditions
 Catheter Care
  • 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)

Key: ADLs = activities of daily living; BR P= bathroom privileges; NS = normal saline; QD = every day; PRN = when necessary; TENS = transcutaneous electrical nerve stimulation.

Current as of September 2007
Internet Citation: Appendix A. Side-By-Side Comparison of a Home Health Plan of Care Form: Development of Electronic Transition Tools for Home Health Care. September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/hcbs/etransitions/etransitionsapa.html