Home Health & Hospice

Insider's Scoop | Build an effective plan of care

Homecare Insider, February 22, 2016

Editor’s Note: This week’s Insider’s Scoop is from The Post-Acute Care Guide to Maintenance Therapy. Medicare coverage for maintenance therapy in the postacute care world has been unclear, causing improper documentation and reimbursement. In this guide, authors Cindy Krafft, PT, MS, and Diana L. Kornetti, PT, MA, provide crucial regulatory information and analysis as well as hands-on, practical advice for care and documentation. The guide also features tools, sample forms, and worksheets that allow for easy comprehension of information. Click here for more information.

Development of a plan of care by the occupational therapist, physical therapist, and/or speech-language pathologist is fundamental to provision of therapy care in home heath. The care plan serves as a road map for care delivery during the beneficiary’s course of therapy services. The greater the detail and objectivity of the initial assessment, the more comprehensive and individualized the resultant care plan.

A plan of care consists of statements that specify the goals, predicted level of optimal improvement, specific interventions to be used, and proposed frequency and duration of the interventions that are required to reach the goals and outcomes (Guide to Physical Therapy Practice, 3rd edition, © 2014, American Physical Therapy Association). The plan of care is the culmination of the physical therapist’s analysis of the assessment and review of systems and medical history, in consultation with the beneficiary, incorporating their individual goal(s).

Care plan design requires the therapist to analyze data gathered from objective tests and measures, factoring in clinical implications related to the severity, complexity, and acuity of the pathology/pathophysiology of diseases, disorders, or conditions that are present. (Guide to Physical Therapy Practice, 3rd edition, © 2014, American Physical Therapy Association)