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This guide establishes a practical process for identifying, documenting, monitoring, and escalating high-risk home health patients in California. The goal is to reduce avoidable hospitalizations, emergency department use, medication errors, falls, wounds, infection risk, missed deterioration, and documentation deficiencies. High-risk patient management must be built into intake, the comprehensive assessment, OASIS, the individualized plan of care, visit notes, case conference, physician or allowed-practitioner communication, emergency planning, and QAPI monitoring.
This guide establishes a practical process for identifying, documenting, monitoring, and escalating high-risk home health patients in California. The goal is to reduce avoidable hospitalizations, emergency department use, medication errors, falls, wounds, infection risk, missed deterioration, and documentation deficiencies. High-risk patient management must be built into intake, the comprehensive assessment, OASIS, the individualized plan of care, visit notes, case conference, physician or allowed-practitioner communication, emergency planning, and QAPI monitoring.