If your patient has rehospitalization risks - those that are documented on M1033 (listed below) - your careplans (i.e. the CMS485) should include goals and interventions for the identified risk.
The careplans for these risks may already be included on the CMS485 for the patient's diagnoses. For example, if the patient has Parkinson's Disease, s/he is already (likely) to be at risk for falls
- and the careplan for Parkinson's Disease should already include Fall Risk Prevention.
However, if the patient does not have a physician-ordered diagnosis directly related to the rehospitalization risk, your careplan should include mitigation for the risk. For example, if the patient has a (4) decline in mental, emotional, or behavioral status in the past 3 months, but no diagnosis of dementia or behavioral issue, a careplan addressing patient safety - related to the cognitive decline - should be included.
(M1033) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply.)
1 - History of falls (2 or more falls – or any fall with an injury – in the past 12 months)
Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a head injury or hip fracture. More than 95% of hip fractures are caused by falling (each year at least 300,000 older people are hospitalized for hip fractures).
If the patient has a history of falls and you are not addressing it as the result of another diagnosis, your careplan should include goals and interventions for fall prevention.
2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months
The reason for the unintentional weight loss should be documented in the Start-of-Care Comprehensive Assessment. The careplan should include goals and interventions for preventing unintentional weight loss.
3 - Multiple hospitalizations (2 or more) in the past 6 months - AND/OR -
4 - Multiple emergency department visits (2 or more) in the past 6 months
A comprehensive assessment includes an assessment of the diagnoses that caused the hospitalization or ER visit. The patient's careplan should include goals and interventions for the unstable diagnoses that caused the patient to seek acute care. Goals and interventions should include ensuring the patients ability to identify symptoms that require a call to the doctor, and the ability to recall and demonstrate the preventive care that controls symptoms.
5 - Decline in mental, emotional, or behavioral status in the past 3 months
6 - Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
Patients with mental, emotional and or behavioral decline are at risk of personal injury. Additionally, a patient's non-compliance (with physician orders) can be a sign of a deteriorating mental, emotional and or behavioral status.
With these symptoms, family and/or caregiver should receive teaching and support on prevention of patient injury - and how to cope with a loved one's cognitive decline.
7 - Currently taking 5 or more medications
The more the patient must remember the more that can go wrong! Your goals and interventions should include patient teaching for any medication s/he is unable to currently unable to recall.
8 - Currently reports exhaustion
A patient who reports exhaustion is at risk for falls and other safety issues. Your careplan should address how to help the patient deal with exhaustion.
9 - Other risk(s) not listed in 1 - 8
Other hospitalization risks include any diagnosis that is currently unstable. As you know, the reason(s) for home care are documented on M1021/M1023. Make sure that M1021/M1023 include the UNSTABLE problems requiring a need for skilled services. If fact, the item "9 - Other risk(s)..." is appropriate to be included on all home care patients - since any unstable diagnosis creates the potential for an ER visit or hospitalization.