One or two of the hardest jobs I've had was working on "skilled" Medicare halls in LTC facilities. These patients are of a much higher acuity than the regular run of the mill nursing home patients. You will be pretty much doing the work of an RN on a medical unit in the hospital. Having sat through a couple of meetings with consultants one LTC brought in for inservicing us told us that they usually recommend that facilities put all their Medicare patients on one wing, hall or one particular area of the facility. The reason is because the nurses who work with these patients have to be aware of what makes these patients "skilled" and to be able to document properly on them. What makes these patients a heavier accuity to work with is because many of them come from the hospitals and still need a lot of very close supervision and care. For a number of reasons they just couldn't be discharged to their own homes. Probably the biggest problem you're going to see is that most of them are pretty wiped out and can't do a whole lot for themselves, at first. This is very typical of elderly people who have a major illness or surgery--it takes them longer to get back to their maximum level of functioning. Many of these patients are going to be getting physical therapy. Reason: PT and OT is one of the major qualifying factors that make a patient "skilled" for Medicare. The other big "skilled" qualifiers are IVs, sterile dressing changes and some continuous oxygen therapy. The major thing to be doing with these patients is to make them the first patients you see after report and check on any wounds they have or breathing problems. Make sure their treatments are getting done and documented. The other thing about them is you will often need to get in touch with the doctor to get changes in medications or treatments. You cannot wait a day or two to get those changes with these patient--it has to be done today. These patients have to have a complete nursing assessment
done and charted at least once every 24 hours, so you and your colleagues need to figure out how to divide this responsbility among you. We used to have the night shift assess the people who were kind of out of it and awake a lot at night. We're talking about a head to toe written assessment. Insofar as your charting each shift on these patients, you want to aim your charting at what is making them "skilled". So, if they are "skilled" because of receiving physical therapy make sure you chart that they have had PT that day and what the nursing staff has been doing with regard to the patients ambulatory status ("walked to BR this shift with one assist--poor balance"). It they are "skilled" for oxygen therapy make sure you chart on their breathing pattern and what their breath sounds are q shift. If they are "skilled" for sterile dressing changes be very sure you are charting on the appearance of the wound including it's measurements and a good description of any drainage that is present.
One facility that I worked at had guidesheets on what absolutely needed to be charted on for each of the major reasons patients were classified as "skilled". Don't know what happened to them. However, if your DON and MDS nurse will let you guys know what the things are that are making each one of these patients "skilled", that will be your guideline as to what is most important to be documenting and attending to in these patients. Your MDS nurse will probably be your best resource person as he/she will be able to tell you what the qualifying reason is for the patient's stay being paid for by Medicare. Your MDS nurse might be able to get you some of the same information we had at my facility to help you with your documentation on these patients. The MDS nurse has to submit an MDS report to Medicare within 15 days of each patient's admission so he/she will know a lot about each of the Medicare patients. They will also know just how long each patient is on Medicare so keep in touch with the MDS nurse frequently to know who is on or going off Medicare. The minute a patient is off "skilled", medicare status, you don't, generally, have to do the same real specific charting required by Medicare. Also, have some way to flag these charts if these patients are being mixed in with your regular nursing homes patients so you will know just who is Medicare. Nothing will be more devastating to the facility than for them to realize that a Medicare patient didn't get the attention demanded by Medicare--they will not get their payment from Medicare and that hurts!
Of course, there will be other issues with them as well--the same old problems with incontinence, confusion, and on and on. Those are the things that landed them on your doorstep or else they'd be home getting home care nurses paid for by Medicare.
The reason LTC facilities like to take in Medicare patients is because of the money they are paid by Medicare. They receive a lump sum payment that covers all the services the patient is going to receive (PT, nursing care, meds). Of course, to save money, the facility is going to try not to have to increase it's nursing staff, have the pharmacy send generics, and utilize PT assistants. That's the way this goes all over the country. I don't envy the task ahead of you. I worked on a 14 bed Medicare unit in a nursing home along with a hall of 16 other regular nursing home patients and it was some of the hardest work I ever did.