Case Conference and Interdisciplinary Communication

Home health is delivered by people who almost never see each other. The PT was there Tuesday, the nurse Wednesday, the aide three mornings a week, and none of them met. Case conference is where the episode gets treated as one plan instead of three.

It is also a Conditions of Participation requirement: the plan of care must be coordinated across disciplines, and coordination has to be documented.

What it is for

Reviewing patients who are not progressing
Deciding who is ready for discharge
Deciding who needs a frequency change, up or down
Flagging patients at risk of hospitalization
Resolving conflicting goals between disciplines
Making sure everyone is working to the same plan

Come with something specific

The difference between a useful conference and a status meeting is preparation. For each of your patients, be ready to say:

Where they are against their goals — met, partially met, not met
What has changed since last time
What you need from another discipline
Whether the frequency still fits
Whether they are on track for discharge, and by when
Anything worrying you that does not fit a box

"Mrs. Okafor is doing fine" is not a contribution. "Mrs. Okafor has met her transfer goals but she's still not managing her medications — I think this is OT, not more nursing" is.

Questions worth asking about every patient

Why is this patient still on service? If nobody can answer crisply, that is the finding.
Are we all working toward the same discharge? Disciplines routinely hold different end dates without realising.
Is anyone seeing something the others aren't? The aide is in the house most often and notices decline first.
What would send this patient to hospital, and are we watching for it?

Ending the drift

The commonest pattern case conference exists to catch: a patient who is stable, pleasant, glad to see everyone, and no longer benefiting from skilled care. Everybody keeps visiting because nobody wants to be the one to raise it.

Raise it. A patient who has met their goals should be discharged — see Discharge. Keeping them on service is not kindness; it is a coverage problem and it displaces someone who needs the visit.

Coordination between conferences

Most coordination happens by phone, message, and note, not in the meeting.

Call the other disciplines when:

You change something that affects their visits
You get a new order
You notice something in their domain — a swallowing concern for the SLP, a transfer that no longer looks safe for the PT
The patient's status changes materially
You are considering discharge

Tell the aide when the aide plan changes, in writing, before their next visit. See Home Health Aide Supervisory Visits.

The communication entry

A communication is an FYI to everyone involved in the patient's care, and it is where a fact gets recorded that no single visit note owns.

Example: Attempted to schedule patient on [date] with no success via phone or drive-by. SN will reattempt next scheduled visit.

Record a communication for:

Refusals to go to the ED — this will happen
A patient who is consistently non-compliant
Falls, which is where you will look for them when writing a 60-day summary
Anything else the rest of the staff needs to know

Document it, or it did not happen

This is the section clinicians leave blank most often, and it is free credit for work already done.

Every visit note has a coordination section. Fill it in:

Conferenced with — name and discipline, and what was discussed
Physician contacted regarding — who you spoke to and what time
Order changes resulting

Take credit for coordination of care efforts. A reviewer reading your chart can only see the coordination you wrote down.

See What Every Visit Note Must Prove.

When disciplines disagree

It happens, and it is usually productive. The PT wants the patient walking to the mailbox; the nurse thinks they are not stable enough. Both are looking at real evidence from different days.

Say it out loud rather than working around each other
Go back to the patient's goals
If it does not resolve, take it to the Field Supervisor or Clinical Manager
Whatever is decided, make sure the plan of care reflects it and everyone knows

What does not work is two disciplines quietly telling the patient different things. The patient believes whoever came most recently, and nobody finds out for a month.