The Care Team and Who Does What
Every role that touches a patient, what each one can and cannot do, and who to go to for what.
Home health is a team sport played alone. You are by yourself in the house, but the episode is run by a group of people you mostly talk to by phone.
In the home
| Role | What they do | What they cannot do |
|---|---|---|
| RN | Assessment, OASIS, teaching, complex procedures, case management, supervision of LPNs and aides | — |
| LPN / LVN | Follow an established plan of care — wound care, medication administration, ongoing teaching | Cannot complete OASIS, cannot perform the initial assessment, cannot establish the plan of care |
| PT | Evaluation, therapeutic exercise, gait and transfer training, strengthening, balance, DME recommendation | — |
| PTA | Deliver a plan the PT established | Cannot evaluate, cannot change the plan, cannot perform reassessment |
| OT | Evaluation, ADL retraining, adaptive equipment, upper extremity function, home modification, functional cognition — applying thinking to daily tasks | — |
| COTA | Deliver a plan the OT established | Cannot evaluate or change the plan |
| SLP | Speech, language, cognition, and swallowing evaluation and treatment | — |
| Home Health Aide / CNA | Personal care — bathing, dressing, grooming — under a written aide plan of care | Cannot perform skilled tasks; cannot change the aide plan |
| MSW | Psychosocial assessment, community resources, financial and housing barriers, caregiver strain, end-of-life planning | — |
The pattern to remember: assistants deliver, licensed clinicians assess and decide. A PTA who thinks the plan needs to change calls the PT; they do not change it.
Behind the scenes
- Field Supervisor / Territory Manager — your first call for clinical or practical problems, and who signs off your competencies
- Scheduler — builds and repairs the schedule; tell them early when something will not work
- Intake / referral team — takes referrals, checks eligibility, confirms the face-to-face
- Coding and OASIS review (QA) — reviews your OASIS and coding before submission; they will send items back, and that is the system working
- Billing — turns compliant documentation into payment; the reason timeliness rules exist
- Clinical Manager / Director of Nursing — clinical escalation, complex cases, complaints
- On-call nurse — covers nights and weekends; they read your notes to understand a patient they have never met
Outside the agency
- Certifying physician — signs the plan of care, takes your calls about changes, and whose records establish eligibility
- Specialists — wound clinic, cardiology, oncology; often where the real plan is being set
- DME suppliers — hospital bed, oxygen, wheelchair, wound VAC
- Infusion pharmacy — for IV antibiotics and TPN
- Reference labs — see Lab Tube Cheat Sheet for who takes which specimen
Who to go to for what
| Question | Ask |
|---|---|
| "Is this a skilled need?" | Field Supervisor |
| "How do I answer this OASIS item?" | QA / OASIS review — before you submit, not after |
| "The patient needs something not on the plan of care" | The physician, for an order. Then update the plan. |
| "I cannot make this schedule work" | Scheduler, as far ahead as you can |
| "The family is struggling financially" | MSW |
| "The patient is refusing care" | Field Supervisor, and document the refusal |
| "The home is unsafe for me" | Leave first. Call your supervisor from the car. |
Case conference
The interdisciplinary team meets regularly to review patients — who is ready for discharge, who needs a frequency change, who is at risk of hospitalization. Come with something specific about your patients, and take credit for the coordination in your notes.
Every conversation you have about a patient with another clinician is coordination of care, and it belongs in the chart. See What Every Visit Note Must Prove.