CMS CJR Bundled Payment - CA LVN's

[Sarah8strong]

Question regarding scope of practice for CA LVN's, my mother had knee replacement surgery with a supposedly great Beverly Hills surgeon and hospital. Discharge planning it turns out was done by an LVN who did my mom's initial assessment and forced her to be discharged early from a skilled nursing facility before she was safe to be discharged. Therapist at Skilled Nursing unit states they are under pressure to get patients out as soon as possible. Surgeon's office states they are under pressure to agree to demands of the LVN's which is hospital sanctioned. My brother called the hospital social worker who states they are also forced to accept the directives of these LVN's as hospital leadership agree with what they are doing. Has the scope of practice for LVN's changed? Is this being approved by medicare to save money?

[MunoRN, RN]

It would be helpful to know why it was an unsafe discharge. Rehab stay coverage is well defined, if at the end of the rehab period the patient is not safe to go home then they might be admitted to an ongoing care facility, but either way they are discharged from their rehab stay.

[Sarah8strong]

When standing even with her walker, she needs help from a second person to steady her balance. She lives alone and fell as she got up to use the commode at night and has been readmitted to a different hospital. I'm frustrated, I feel she should have been allowed to stay longer than 6 days to recover.

[Sour Lemon]

Question regarding scope of practice for CA LVN's, my mother had knee replacement surgery with a supposedly great Beverly Hills surgeon and hospital. Discharge planning it turns out was done by an LVN who did my mom's initial assessment and forced her to be discharged early from a skilled nursing facility before she was safe to be discharged. Therapist at Skilled Nursing unit states they are under pressure to get patients out as soon as possible. Surgeon's office states they are under pressure to agree to demands of the LVN's which is hospital sanctioned. My brother called the hospital social worker who states they are also forced to accept the directives of these LVN's as hospital leadership agree with what they are doing. Has the scope of practice for LVN's changed? Is this being approved by medicare to save money?

I've never heard of an LVN or any other sort of nurse forcing a doctor to discharge a patient. Who, exactly, is "surgeon's office"? It doesn't sound like their perception is an accurate one.

[MunoRN, RN]

Was she discharged from the hospital or SNF after six days? Is the same LVN supposedly deciding when patients get discharged from both the hospital and the SNF? What was the plan before surgery?

[Sarah8strong]

That's what's happened to my mom. Her knee surgeon's office manager says they had no part in her discharge from the SNF. She was discharged to the SNF from the hospital under the care of the hospital's medical group MD. I'm also a nurse and find so many things unusual about my mom's experience, I wish I'd had her home with me after her surgery.

[MunoRN, RN]

Was her hospital stay 6 days? Typically the hospital stay for a knee replacement is less than 6 days, if for some reason they still need ongoing nursing care/rehab then they are initially sent for outpatient rehab which is also usually fairly short, if they need ongoing nursing care beyond that then that's a separate thing.

[Sarah8strong]

She was in the hospital for two nights not three nights which is what we expected. Medicare have this new plan for hip and knee replacement surgery patients which means they can be discharged to skilled nursing facilities from the hospital with less tham 3 midnight stays in the hospital. she was discharged from the SNF after she had been there for five nights.

I'm concerned, why would the hospital support such practice.

[MunoRN, RN]

She was in the hospital for two nights not three nights which is what we expected. Medicare have this new plan for hip and knee replacement surgery patients which means they can be discharged to skilled nursing facilities from the hospital with less tham 3 midnight stays in the hospital. she was discharged from the SNF after she had been there for five nights.

I'm concerned, why would the hospital support such practice.

It's usually 3 nights total, I think the national LOS average is around 3.1 days, and that's total length of stay, 3 nights and then home. So if your mom got 7 nights in combined hospital/SNF recovery, then that actually seems pretty good. I'm still not clear what role the LPN played in all of this.

[Sarah8strong]

Medicare got and understood the nuances of my mom's case which includes patient safety amongst other things.

[amoLucia]

Facility discharge criteria is usually cut & dry. And that means insurance reimbursement for skilled services, therapy or nursing.

Criteria is what drives discharge, not perception of needs. .Pt participation in skilled nsg or Therapy (or lack of participation) and continuing to make progress (rather than plateauing) are key factors while the pt is instituionalized. If you Mom's situation is unsafe because she lives alone and there's steps to get to the second floor bathroom and 3 cats need too be cared for and rugs cover all the floors. Meals will need to be provided as well as hygiene. That's safety and homecare needs, but that becomes part of discharge planning with selective home care services from Visiting Nurse. There is NO skilled need there. No facility can control that. Routine homecare is expected to be provided thru services & planning set up by the family.

Re the LVN scope of practice - she's prob a case manager who is experienced & educated with all the rules & regs as manadated by CMS for Skilled Services and Insurances for reimbursements.

I think you may be facing one of the dilemmas facing many folk when supply & demand expectations for family care services do not meet. And that's a very difficult situation to remedy.