CVHCare is an extension of your patient’s medical care program. The need for quality ancillary services, such as home health, to care for our aging population continues to grow. Home health care is an essential component in preventing avoidable and costly readmissions to hospitals, as well as reducing cost of care by promoting a seamless transition from the hospital to home through a partnership approach.

 

• Offers outcome-based care

• Strive to avoid unnecessary hospitalization and emergent care

• Advanced treatment of chronic diseases, such as Diabetes, Congestive Heart Failure and Hypertension

• Offer the highest level of home healthcare, enhancing results and patient satisfaction

• Serves as at-home eyes and ears to the physician, by assessing patients on a regular basis and providing timely reports.

 

With our clinical expertise, we are able to transition even the most complex cases from the hospital to home. After a referral is made to CVHCare, we follow it from admission to discharge, striving to ensure patient expectations are met. We will work closely with our referral sources to provide prompt turnaround, appropriate coordination of services and ongoing open communication.

 

Re-Admission Prevention through Innovative Discharge (RAPID) Program

RAPID is a home based disease management protocol written exclusively for CVHCare. The focus of the program is to prevent re-hospitalization among our patients with chronic disease. Patients are enrolled in RAPID with an understanding and agreement of compliance and active participation on the part of both the patient and the family or caregivers. The program is utilized in conjunction with individual Chronic Illness Management Pathways to effectively manage patient’s chronic disease and prevent re-admissions.

 

Medicare Guidelines

In order to qualify for home health care there are certain conditions that a prospective patient must meet:

1. The patient must be homebound. Based upon Medicare criteria, “homebound” is defined as:

   • Leaving the home would require the patient to make “considerable and taxing effort."

   • The patient can leave the home only for infrequent, short absences. Example include medical appointments, short walks, appontments with the hairdresser, or attendance at religious services. 

   • An individual may be temporarily homebound while recovering from surgery, serious illness or trauma.

2. Care must be medically necessary. Home helath care is usually provided for conditions that are acute and serious vs. chronic and stable.

3. Care must be provided on a part-time or intermittent basis.

4. Patient must require at least one skilled professional service, such as nursing, physical therapy or speech & language pathology.

5. Care must be provided by a Medicare-Certified home health agency.

6. The patient must have a signed physician’s order for the requested service(s).

7. Services must be delivered in the patient’s home or primary place of residence.

​

Admissions Processing and Intake

CVHCare works with a variety of referral sources, including hospital discharge planners, physicians, skilled nursing facility social services staff, assisted living facility wellness coordinators, board and care administrators and family members. Whether you are seeking home health care services for a loved one or you are a healthcare professional making a referral, our goal is to make the process as smooth and straightforward as possible.

 

Our Intake team will only need some general information to verify eligibility:

• Patient demographics (name, address, contact information)

• Physician’s name and phone number

• Insurance information

• Pertinent medical information (specific orders, if available)

 

Although a majority of the referrals are received during normal business hours, urgent and/or after hours intake support is available 24-hours a day at (510) 825-6952.

 

After obtaining orders from the treating physician, patients are contacted within 24 hours by a Patient Care Specialist to schedule the first visit. The purpose of this initial assessment is to complete admission paperwork, assess a patient’s individual needs and determine if they fully meet Medicare home health requirements. This first visit is usually performed by a registered nurse, physical therapist or occupational therapist. A broad range of patient physical/clinical factors will be evaluated during the first one or two visits, including medication, safety, caregiver support and environment. Based on this initial assessment, the CVHCare clinical care team--in concert witht the patient's physician--will develop an individualized plan of care. The inividualized plan of care will be provided to the patient’s primary care physician (PCP) for approval and an authorization signature.

 

Face To Face Patient Meeting / Orders For Home Health Services

A patient’s primary care physician (PCP) must provide signed orders to initiate the care delivery process. A computer generated document (referred to as a 485), provides detail about the Plan of Care, the original orders and any clinical assessments. The 485 must meet regulatory requirements and requires a physician signature within 30 days of the start of care. Additional orders (signed certifications) may be required during the time frame home health care is provided. Some examples of these additonal orders are: Change in Plan Of Care, Durable Medical Equipment order, Significant Change In Condition, and Resumption Of Care.

 

Effective April 1, 2011, Medicare requires that health care providers have a Face-To-Face (F2F) meeting with patients for home health and hospice care. This Face-to-Face (F2F) requirement is intended as a tool for reducing fraud, waste, and abuse. The Face-to-Face requirement ascertains that physicians have met with home health patients to ascertain their specific care needs and orders are based on current knowledge of a patient’s condition.

 

The F2F requirement can also be satisfied if a non-physician practitioner (NPP) sees the patient, if the NPP is working for or in collaboration with a physician. Medicare will also allow hospital physicians to certify the need for home health care based on their face to face contact with the patient in the hospital. The hospital physician can initiate the orders for home health services and “hand off” the patient to his/her community-based physician to review and sign off on the plan of care.

 

The physician must document that they or a non-physician practitioner (NPP) visited with the patient in a Face-to-Face meeting. The physician or NPP must also document that the patient is homebound because of his clinical condition, and has a need for skilled services. The Face-To-Face encounter must occur within 90 days prior to the start of home health care or within 30 days after the start of care.