CMS SOM App. B, Tag G804

must report changes in the patient’s condition to a registered nurse or other

appropriate skilled professional, and must complete appropriate records in

compliance with the HHA’s policies and procedures.

Interpretive Guidelines §484.80(g)(4)

As noted in 82 FR 4532, interdisciplinary teams work together, each member

contributing their knowledge and skills, interacting with and building upon each other, to

enhance patient care. The interdisciplinary team model is the foundation of care in other

health care providers, such as hospices and complex chronic care management practices.

HHAs may choose to develop interdisciplinary team models based on the experiences and

knowledge developed by these similar care providers, or may develop their own

strategies and structures to create effective interdisciplinary teams. The term

“interdisciplinary” refers to an approach to healthcare that includes a range of health

service workers, which may include but is not limited to, MDs, RNs, LPN/LVN, PT &

Physical Therapy Assistant (PTA), OT & Occupational Therapy Assistant (OTA), SLP,

MSW, and HH aides.

During interdisciplinary team meetings, all HHA staff involved in the patient’s care must

be present for, and, where appropriate, should contribute to, any discussion regarding the

patient’s care. Since home health aides play an integral role in the delivery of HHA

services and have frequent and/or prolonged encounters with patients, their input as

members of the interdisciplinary team is important for information sharing and their

participation in the team should be reflected in the visit notes of the clinical record. The

HHA aide may participate in person, electronically or via telephone.