Policy Manual sample

MDT Home Health Care Agency, Inc. 182 COORDINATION OF SERVICES PURPOSE: • To ensure effective and appropriate coordination and continuity of care, treatment and/or services to promote positive patient outcomes. • To uphold patient rights. • To support the goals and objectives outlined in the plan of care. • To prevent duplication and conflict of care, treatment and/or services. POLICY: • Care, treatment and/or services are provided by MDT Home Health Care Agency, Inc. in an interdisciplinary, collaborative manner as appropriate to the needs of the patient and the Agency’s scope of service. • All Agency personnel, including providers under contractual arrangement, providing care, treatment and/or services to MDT Home Health Care Agency, Inc. patients maintain liaison with other healthcare team members to ensure effective coordination of efforts and to support the goals and objectives outlined in the plan of care. • The clinical services provided by MDT Home Health Care Agency, Inc. personnel and/or providers under contractual arrangement with MDT Home Health Care Agency, Inc. shall complement one another and shall be coordinated by MDT Home Health Care Agency, Inc. to assure quality patient care/services and to promote positive patient outcomes. • Whenever possible, the patient’s care, treatment and/or services are provided by a limited number and consistent team of Agency personnel. • When the patient is receiving care, treatment and/or services from other organizations/ providers, MDT Home Health Care Agency, Inc. ensures that the responsibilities of the Agency and other organizations/providers are collaborative and exclusive. • Communication is maintained between those providing services regarding changes in the patient's needs, services or care to be provided or goals that impact the overall care, treatment and/or services. • The plan of care is reviewed in its entirety by the attending physician and MDT Home Health Care Agency, Inc. as often as the severity and/or instability of the patient’s condition requires, but at least every 60 days or more frequently when there is a beneficiary elected transfer; a significant change in condition resulting in a change in the case-mix assignment; or a discharge and return to MDT Home Health Care Agency, Inc. during the 60-day episode.