Part of the responsibility of the interdisciplinary team (IDT) is to include patients, and if requested, their care partners and family members in both developing/setting goals and reviewing the patient plan of care.
Is it acceptable to hold a plan of care meeting with the IDT and the patient, their care partner or family members (if requested) via telephone conference? As stated in the CMS Interpretive Guidance for the Conditions for Coverage for End-Stage Renal Disease Facilities, the answer is “yes.”
“A substitute mechanism for a team conference needs to facilitate discussion among team members about the information gathered from the comprehensive patient assessment and provide the opportunity for team coordination and development of an effective, individualized plan of care for the patient to ensure the desired outcomes are achieved. To facilitate full team participation in conferences, any member, including the patient, may participate through telecommunication.”
CMS Interpretive Guidelines (see page 205): https://esrd.ipro.org/wpcontent/uploads/2017/08/InterpretiveGuidelines.pdfÂ
For more information on the regulations on plans of care, see the CMS Conditions for Coverage for end-stage renal disease facilities. Subpart C – Patient Care: https://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol5/xml/CFR-2011-title42-vol5-sec494-90.xml