Care Team Collaboration in Home Health

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Dr. Williams is a family physician that does home health visits two days a week. She sees a mix of patients that have just been discharged from the hospital and patients with chronic conditions that are regularly monitored. Her day can go very differently depending on the technology that she has available. First, let’s go through Dr. Williams’ day with her standard EHR tools, and then we will view her day when she has care team collaboration technology.  

With the EHR Only

Dr. Williams heads to her first appointment at 9:00AM. The patient, 68-year-old Mr. Johnson, is someone that Dr. Williams visits monthly. He has heart disease and high blood pressure, and has trouble getting around. During this visit, Dr. Williams takes notes on her laptop. She checks Mr. Johnson’s vitals and tries to compare it to his last few vitals, but it takes her 12 clicks to find the last three vitals, and now she is rushing. As she packs up, Mr. Johnson mentions that his knee has been bothering him. Dr. Williams checks his knee and says she will put in a referral to physical therapy as a first course of treatment. Since she has already put her laptop away, she quickly adds it to a word doc on her phone and makes a mental note to add that info to Mr. Johnson’s chart later. 

After seeing three other patients, Dr. Williams has her last appointment, 74-year-old Mrs. Sheffield. Mrs. Sheffield has problems with her knees and needs a cane to get around. During their visit, Mrs. Sheffield tells Dr. Williams that she saw an endocrinologist this week, and her prediabetes has progressed into diabetes. While the endocrinologist gave Mrs. Sheffield some care instructions, Mrs. Sheffield wants Dr. Williams to be in charge of managing her care, since Dr. Williams has been her physician for 15 years. Dr. Williams writes down everything the endocrinologist told Mrs. Sheffield to do, and says she will review the endocrinologist’s note when she gets it and help with coordination. She makes a note in the chart that Mrs. Sheffield will need to schedule appointments with ophthalmology and podiatry in the next couple months, as well as get her diet reviewed by a nutritionist.

Eventually Dr. Williams returns to the office 25 minutes later than she was planning to. She works on the patient notes, starting with Mr. Johnson. She remembers that she said she would put in a referral for physical therapy, but she can’t remember where those notes are, so she puts in the referral but doesn’t add any codes for the advice and examination services she did. For Mrs. Sheffield, she finishes detailing the appointment, and then adds in a sentence towards the end about reminding Mrs. Sheffield at her next appointment to schedule those specialist appointments. She spends 90 minutes completing the patient charts and responding to messages. She still has a few things to finish up, which she plans to do at home. Dr. Williams finishes her last 45 minutes of charting at her house after dinner. 

While this may seem cumbersome, there are also other potential problems. For Mr. Johnson, Dr. Williams didn’t add any of the work she did to examine his knee. This means that this information isn’t added to the chart for future reference, and that she is not getting reimbursed for it. Second, let’s think about Mrs. Sheffield. Dr. Williams put a note in her chart to have Mrs. Sheffield schedule ophthalmology and podiatry appointments, but there are so many other notes that this can easily be skipped over at the next appointments, delaying the appointments until one of them remembers they need to be scheduled.  

With Care Team Collaboration 

If Dr. Williams had a care team collaboration platform, like CareAlign, here is how her day could have gone: 

Better Documentation 

For her first appointment with Mr. Johnson, it takes Dr. Williams just two clicks to see a graph of Mr. Johnson’s vitals, which she shows him to help him understand how he is doing. She saves a little time and improves the patient’s understanding of his health. Then, as Mr. Johnson tells her about his knee,  Dr. Williams can easily add this note to CareAlign’s wiki, where it can be added to the chart and be billed for. She can also add a task to have Nurse Kevin prepare the referral, and it is done before she gets to her next appointment. 

Improved Coordination 

For Mrs. Sheffield, Dr. Williams adds “Diabetes” as a new problem. She quickly adds tasks to have Mrs. Sheffield schedule an ophthalmology appointment and speak with a nutritionist. If Mrs. Sheffield has an acute care episode and then returns to Dr. Williams for regular care, Dr. Williams will easily see the tasks, and can remind Mrs. Sheffield to schedule those appointments. Dr. Williams can also schedule these tasks for Mrs. Sheffield’s next follow-up appointment, or put a note for Nurse Nick to do this. 

Time Saved

Dr. Williams arrives at the office at the time she anticipated. Instead of rewriting all her patient notes, she can just import the notes from CareAlign into her EHR. Finishing these notes and checking her messages takes less than an hour. Then she heads home, where she doesn’t have work to finish. 

As seen in this example, CareAlign’s care team collaboration platform can greatly improve coordination and communication with home health services. Want to learn more? Read a case study about how CareAlign helped home healthcare clinicians improve the accuracy of their RAF scores with better documentation capture, or learn more about CareAlign at