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Glossary

Plan of care

The written plan that sets what care a patient will receive, from whom, how often and toward what goals. In home health it is established and reviewed by the certifying practitioner; in PACE it is written by the interdisciplinary team; in structured family caregiving by the provider agency's nurse.

Also POC, care plan, CMS-485

“Plan of care” names three different documents in the three settings Vivlio serves, and in each one it is written from whatever records are in hand on the day.

Home health. Under 42 CFR 484.60 each patient must receive care under an individualized plan of care established and periodically reviewed by the certifying physician or allowed practitioner, in consultation with the agency’s staff. It must carry the diagnoses, the services and their frequency, the goals, the medications and treatments, the safety measures, and the patient’s risk of hospitalization. It is reviewed at least every sixty days. The old CMS-485 form is no longer required but is still the shape most agencies use. The plan follows the comprehensive assessment, so a medication list or diagnosis that the assessment missed is missing here too.

PACE. Under 42 CFR 460.106 the interdisciplinary team develops the plan of care from its initial comprehensive assessment, with the participant and caregiver, and reviews it at least semiannually and whenever the participant’s condition changes. It covers every domain the team assessed, and the PACE organization is responsible for every service in it, including the specialist and hospital care the participant received before enrollment.

Structured family caregiving. The provider agency’s nurse writes the plan at the start of service, from the first home visit and the records available then, and it sets the caregiver’s training and the visit cadence. Each state’s rule names what it must contain; what the SFC nurse needs before the first visit lists the records the plan rests on.

In all three the plan is only as good as the history it was written from, which is the reason outside records belong in hand before it is written rather than after.

Where it is defined

Vivlio for home healthThe face-to-face note, orders, discharge summary and medications, assembled before the first visit.

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  • Coverage comes firstVivlio retrieves from providers, hospitals and health systems it can reach through national exchange networks and direct connections. Name the facilities your patients come from on the form and we check coverage before anyone spends thirty minutes on a demo.
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  • Patients and files at volumeThis is built for intake that runs every day. For one record, once, your patient can request it from the provider directly, and that will be faster than going through us.
  • Treatment, with the paperwork doneProduction access needs an NPI, a declared purpose of use and a signed BAA. Nobody swipes a card onto live PHI.

If none of those describe you, say so in the last field and we will come back in writing instead of booking a call.

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