Policy Manual sample

MDT Home Health Care Agency, Inc. 183 • Case conferences are held at least bimonthly or more often if necessary, to facilitate multidisciplinary coordination and communication of patient care. Case conference also occurs spontaneously/informally between healthcare team members and are documented in the patient’s medical record and communicated to the Clinical Supervisor. • When the patient is referred to another provider, the patient/family shall be informed of any financial benefit to the referring organization. • The individual designated to coordinate the services provided by MDT Home Health Care Agency, Inc. is qualified through education, training and/or experience and is one who: • Understands the scope and types of services which are provided • Understands the required personnel standards and knows which personnel within MDT Home Health Care Agency, Inc. meet the criteria • Understands the relationships among staff providing services and the responsibilities of each party involved • Understands the needs of the patient population served by MDT Home Health Care Agency, Inc. PROCEDURE: • The individualized plan of care should be available to all appropriate staff. • The designated MDT Home Health Care Agency, Inc. staff member should initiate/ maintain communication with appropriate parties and individuals involved by:  Meeting or telephoning pertinent staff  Initiating telephone or onsite conferences with involved parties  Participating in patient case conferences • Coordination of service activities is documented in the patient's home care record. Each record shall contain up-to-date information regarding: • The services that are being provided • The responsibilities of each service/discipline • The interventions provided along with the patient/caregiver response • Communication between involved parties