A well-structured plan of care is the foundation of quality home health care, ensuring that patients receive individualized care that meets their needs. Developing an effective plan of care requires adherence to the Home Health Medicare Conditions of Participation (CoPs) and the Accreditation Commission for Health Care (ACHC) Home Health Standards.

Required Components

A home health plan of care outlines the medical, rehabilitative, and supportive care provided to a patient with an acute or chronic condition. It is developed from an interdisciplinary perspective, incorporating input from the patient’s physician, home health nurses, therapists (physical, occupational, speech-language), social workers, and other relevant professionals to ensure a comprehensive, whole-person approach. Together, these interdisciplinary clinicians work to meet the medical, functional, psychosocial, and emotional needs of the patient while promoting recovery, independence, and safety in the home environment.

Medicare Conditions of Participation (CoP) at 42 CFR §484.60 require that, a home health plan of care includes:

• All pertinent diagnoses.
• The patient’s mental, psychosocial, and cognitive status.
• The types of services, supplies, and equipment required.
• The frequency and duration of visits to be made.
• Rehabilitation potential.
• Functional limitations.
• Activities permitted.
• Nutritional requirements.
• All medications and treatments.
• Safety measures to protect against injury.
• A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.
• Patient and caregiver education and training to facilitate timely discharge.
• Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient.
• Information related to any advanced directives.
• Any additional items the HHA or physician or allowed practitioner may choose to include.

ACHC-accredited home health agencies must also ensure that each POC aligns with ACHC standard HH5-3A and includes:

• Start of care date.
• Certification period.
• Patient demographics.
• Caregiver needs and availability of support.
• Problems and needs.

Developing the Plan

The basis of an effective and individualized plan of care are the initial and comprehensive assessments. The patient’s condition and risks must be established and the home health agency must ensure that patient needs and planned interventions align with Medicare requirements for skilled care eligibility. These will be consistently reevaluated throughout the period of service and all patient care orders, including verbal orders, must be recorded in the plan of care.

Setting Goals and Establishing Interventions

Once the initial and comprehensive assessments are complete, the home health team collaborates with the patient and their family to establish clear, measurable goals. These may include:

• Improving mobility and physical function through skilled therapy.
• Managing chronic conditions such as diabetes, heart disease, or COPD.
• Providing wound care and preventing infections.
• Teaching self-care strategies to enhance independence.
• Reducing hospital readmissions through preventive care.

Medicare and ACHC emphasize interdisciplinary collaboration, requiring input from all disciplines involved to ensure a comprehensive, coordinated approach.

Implementing and Updating the Plan

A home health plan of care is a dynamic document that must be reviewed and updated regularly to reflect changes in the patient’s condition. Medicare CoP mandates reviews at least every 60 days—sooner if significant changes occur. Any new or evolving conditions must be addressed as revisions to the plan of care, while interventions for problems that have been resolved should be discontinued as appropriate.

Maintaining Compliance

Care planning occurs with every patient interaction and the plan of care is frequently updated as a result. A structured, patient-centered approach integrating the requirements of Medicare CoPs and ACHC Home Health Standards ensures that the plan of care is a reliable guide for the current services to be delivered to each patient. By conducting thorough assessments, setting clear goals, maintaining interdisciplinary coordination, and ensuring continuous updates, home health providers can deliver high-quality, personalized care. This approach enhances recovery, independence, and quality of life for patients receiving care in their homes.