Module guide · Clinical

Home Care

Built around 42 CFR § 484, Medicare's Conditions of Participation for home health: a physician's referral becomes a certified 60-day plan of care, which schedules GPS-verified field visits and telehealth sessions and, where ordered, enrolls a patient in remote monitoring.

Overview Dashboard Referrals Plans of care Managing a plan Home visits Telehealth Remote monitoring My patients Analytics Good practices

What this module is for

Access splits three ways: a broad clinical/coordinating group can view most screens, a narrower management group handles intake and scheduling, and one screen is physician-only.

Who uses it

Nurses, home health aides, care/homecare coordinators, nurse managers, physicians, NPs/PAs, directors, quality, compliance, and billing staff can view plans and visits. Referral intake, new plans, visit scheduling, and analytics are limited to coordinators, managers, directors, quality, and compliance. My Home Care Patients is physician-only.

Where to find it

Open Home Care from the sidebar. A dashboard plus eight sub-areas: Referrals, Plans of Care, Visits, Telehealth, Remote Monitoring, My Home Care Patients, Analytics, and Import/Export.

1
Refer
A physician-signed referral comes in, is accepted, and becomes an intake.
2
Certify a plan
A 60-day CMS-485 plan of care is created: diagnoses, ordered services, frequency, and vital-sign thresholds.
3
Deliver care
Field visits (EVV-verified) and telehealth sessions are scheduled and documented against the plan.
4
Monitor & recertify
Remote monitoring watches vitals between visits; every 60 days the plan is recertified or the patient is discharged.

A few terms you'll see throughout

EVV (Electronic Visit Verification) is the GPS-stamped check-in/out federal law requires for home visits. OASIS/PDGM fields are Medicare's case-mix and reimbursement data. RPM is Remote Patient Monitoring, device readings compared against thresholds set on the plan.

Dashboard

Eight stat tiles surface exactly what needs attention across the whole program, plus a patient search and quick links into every sub-area.

Stat tiles (click through to the relevant list)

Field	What it means
Pending Referrals, Active Plans
EVV Unverified	Visits missing electronic verification.
Physician Notifications	Generated from field-visit findings awaiting physician review.
Telehealth (24h), Unbilled Telehealth
Unacknowledged RPM Alerts, Prior Auths Expiring	Within 14 days.

Searching a patient auto-opens their plan if they have exactly one, lists multiple plans to choose from, or offers to start a referral if they have none.

Referrals

The intake queue for physician-signed orders starting home health service.

"New Referral" form

Field	What it means
Patient, Referral Date*
Referring Physician, Referring NPI	NPI must be exactly 10 digits.
Priority	Routine (default), Urgent, or STAT.
Primary Diagnosis Code (ICD-10-CM), Description*
Requested Services*	At least one of 17 service types, e.g. Skilled Nursing, Physical/Occupational/Speech Therapy, Home Health Aide, Wound Care, Palliative Care, Medication Management, and more.
Homebound Reason*	Explicitly required for Medicare home health eligibility.
Payer Name, Member ID, Prior Auth Number & Dates, Authorized Visits	All optional.
Prognosis, Allergies Summary, Isolation Precautions, Notes

The queue filters by status: Pending, Intake, Active, Discharged, Rejected. Accept moves it to Intake and offers a shortcut straight into a new plan; Reject requires a typed reason. Once Intake, Create Plan carries the referral's details forward.

Plans of care

Search active and past 60-day certified episodes; New Plan creates one, optionally pre-filled from an accepted referral.

"New Plan of Care" form (CMS-485 / 42 CFR § 484.60)

Field	What it means
Patient, Certifying NPI*	NPI must be exactly 10 digits.
Cert Period Start, End*	Defaults to a 60-day span, the CMS standard episode length.
Primary Diagnosis Code, Description*
Ordered Services*	Same 17-value service list as referrals.
Frequency*	Daily through Monthly, plus As Needed (PRN) and Continuous; Visits Per Week and Total Authorized Visits set the cap.
Vital Sign Thresholds	BP, heart rate, SpO2, weight-gain, and glucose min/max, these drive remote monitoring alerts once RPM is enabled.
Enroll in RPM now	Checkbox; reveals a Monitoring Device ID field.
Medication/Diet Orders, Activity Restrictions, Equipment, Safety Measures
Primary Caregiver Name, Phone, Relationship

Active — currently receiving care

On Hold — temporarily paused

Discharged — care concluded

Discontinued / Transferred — ended early, or moved to another agency

Managing a plan

Every plan has five tabs, Overview, Visits, Telehealth, Monitoring, Export, plus lifecycle actions in the header.

Header lifecycle actions (status-gated)

Field	What it means
Hold	While Active; requires a typed reason.
Discharge	While Active; pick a reason (Goals Met, Patient Declined, Hospitalized, Deceased, Non-Compliant, and more), plus an optional summary.
Recertify	Closes the current episode and opens a new 60-day certification carrying forward diagnoses and orders, this creates a brand-new plan record, not an edit.
Resume	While On Hold; immediate, no confirmation.
Start/Stop Remote Monitoring	Prompts for a Device ID the first time it's enabled.

An amber banner warns when recertification is coming due, so coverage doesn't lapse. The Overview tab shows diagnoses, frequency and visits used, ordered services, goals, vital thresholds, caregiver and payer info, and, once assessed, OASIS/PDGM case-mix fields (HIPPS code, Clinical Grouping, Functional Impairment Level).

Export offers a FHIR R4 Bundle, a structured CMS-485 JSON, a Visits CSV, an HL7 v2.5.1 ADT^A01 message, a full ZIP archive, and a date-ranged RPM Readings CSV, for interoperability, audits, or agency transfer.

Home visits

Scheduling enforces the plan's authorized-visit cap; field documentation happens on the visit itself.

Scheduling

Pick a plan (auto-selected if the patient has only one), a clinician, a service type (limited to the plan's ordered services where possible), start/end times, and CPT/diagnosis codes. Scheduling is blocked outright once the plan's remaining-visit count hits zero.

My Visits

A field clinician's own daily queue, scoped to their login. Check In/Check Out buttons capture GPS location inline for EVV compliance without leaving the list.

On the visit itself: EVV Check-In/Check-Out (geolocation-captured), Mark Missed and Cancel (both require a typed reason), and Reschedule (creates a new visit record). Once In Progress, a full clinical documentation form opens: vitals, pain scale, a SOAP note, interventions, caregiver education, a Morse Fall Risk Score (0–125), and checkboxes for incidents, medication changes, supervisory visits, and physician notification. Once Completed, documentation locks. A red banner warns if recorded vitals fall outside the plan's safety thresholds.

Telehealth

Remote visits scoped to home care, citing CMS's telehealth conditions (42 CFR § 410.78).

"Schedule Session" form

Field	What it means
Patient, Provider*
Platform	Zoom for Healthcare, Doxy.me, Teladoc, Amwell, Webex Health, or Custom.
Session Type	Initial Evaluation, Follow-Up (default), Medication Review, Wound Check, Mental Health, Chronic Care Management, or Care Coordination.
Place of Service	CMS billing code 10 (patient in home, default) or 02 (patient not in home).
Patient State*	Exactly 2 letters, validated for interstate provider-licensure compliance.
Enable recording	Checkbox; notes it requires patient consent.

The list has three tabs: Upcoming (48h), Unbilled, and Missing Consent. In the session room, status moves Scheduled → Waiting Room → In Session → Completed, with Cancel, Report Technical Failure, and Mark No-Show as exits, each asking for a reason. Completing a session opens a documentation panel (chief complaint, self-reported BP/HR/SpO2, CPT/diagnosis codes, HIPAA consent checkbox) before Mark Billed becomes available.

Remote monitoring

A program-wide RPM alert inbox (CMS CPT 99453–99458) plus per-patient device trend charts.

Alert inbox

Each unacknowledged alert shows severity, the triggering reading, and the device. Eighteen alert types cover blood pressure, heart rate, SpO2, glucose, rapid weight change, temperature, respiratory rate, pain level, falls, missed medication, no activity, and offline devices.

Patient trends

Thirty-day line charts for six vitals (systolic/diastolic BP, heart rate, SpO2, glucose, weight), each with the plan's threshold lines overlaid, plus a full reading history table.

Acknowledging an alert requires an action

Action Taken is a required field, e.g. "Called patient, adjusted medication, scheduled urgent visit," and there's no un-acknowledge once submitted.

My home care patients

A certifying physician's personal panel, physician-only, of their own plans.

Patients needing recertification or with unacknowledged RPM alerts sort to the top and get a highlighted card. From here a physician can jump straight into scheduling a visit or telehealth session, or start/view remote monitoring, without navigating through the broader Plans list.

Analytics

Program-level reporting: referral pipeline, plan census, diagnosis mix, and RPM alert trends over the last 30 days.

Charts

Field	What it means
Referral Pipeline	Counts by referral status.
Plans by Status
Top Diagnoses (Active Plans)	Top 10 ICD-10-CM codes by frequency.
RPM Alert Breakdown	Counts by alert type, last 30 days.

Import/Export (a separate screen) mirrors a plan's export options program-wide, and adds import for FHIR bundles, visit CSVs (idempotent, skipped by FHIR encounter ID), RPM reading CSVs, and raw HL7 ORU^R01 messages.

Good practices

Watch the remaining-visits counter

Scheduling is hard-blocked once a plan's authorized visits run out, request a prior-auth increase before the count hits zero, not after.

EVV check-in/out every visit, no exceptions

It's a federal compliance requirement, not just a convenience, and the dashboard tracks unverified visits as its own metric.

Reason-required actions are there for the audit trail

Rejecting a referral, holding a plan, cancelling a visit or session, and acknowledging an RPM alert all require typed justification, by design, for compliance review.

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