PLAN OF CARE
HOSPITAL VS COMMUNITY
The Plan of Care is a requirement for patients receiving the Medicare home health benefit. Community physicians (primary care physicians and specialist) who order home health services for their patients would naturally receive the plan of care since the patient continues to be under their care during the duration of the home health services. In these scenarios, community providers play the role of referring and certifying physicians.
However, when the patient receives home health services ordered from a hospitalist, the referring and certifying physicians may be two distinct parties. As a post-acute focused home health company, we understand the importance of transitioning the patient back into the community. One of the keys to a successful transition is in proper coordination with primary care physicians. At every admission, we perform we encourage and instruct our patients to follow up with their primary care physician so that all their post-hospitalization needs are met. In many instances our nurses or therapists may assist the patient in scheduling their follow up appointments. We also coordinate with the primary care physician and other physicians who may be treating the patient. If the patient is having trouble seeing their primary care physician, the Plan of Care may be directed to the hospitalist since they ordered the services and was the last doctor to treat the patient.
