Medicare and Skilled needs

[spejsa]

Does anybody have any information regarding what Medicare considers skilled visits?? Our agency has said a lot about the nursing needing to have a skilled need if in a home.. But, I always get referrals that the office sends me to do and it goes like this... Today, I had one that I got yesterday. The woman was DC'd from the hospital. She had a diagnosis of possible cholecystitis. She had been in the hospital and the paperwork indicates that they last did labs on her a few days ago.. The referral states that we were to admit to do a lab that needed to be sent to the Dr. prior to an appt this coming Friday. It is for Amylase, Lipase, CBC, and CMP. I called and spoke with her nephew who states that she is doing ok and this was all that she would need done as she lives in an assisted living center that has CNA's and an RN that oversee her care. He said she is very well taken care of. So, basically, if I go out they will probably not need me to go out and see her all the time... The agency says we have to have 5 visits in a cert. period... It may not happen if there is nothign to teach (the patient has Alzheimer's and I have found most of the nurses in these situations are not teachable...). So, do I go out and do blood draw and then schedule no further visits??? She has Dementia, Depression, and HTN... She is in her 80's. Just needing advice.

[spejsa]

It is an abscess on the buttocks from a "spider bite". I think we can go with less than daily dressings but the LPN disagrees. I am waiting for the MD to evaluate the wound to give orders. The LPN is quick to say "well, we have to do daily until the Dr. tells us differently". But, I am the one that wrote the daily order 2 weeks ago on SOC? And, it is doing well and has healed very well, but we are still packing. I don't think we need to but she thinks we do?

[spejsa]

The reason I wish to discharge is the drug issue. I have not seen anybody do a drug deal but I know there are drugs in there. There are multiple red flags.. and it worries me being in the home at all. And, the patient saying people are taking his pain meds, etc...

[KateRN1]

Yes, the patient has issues, but having issues is not a reason to discharge from home health care. Daily wound care is allowed up to 21 days without an end date, after that you need to provide a reasonable date when daily dressings are expected to stop. I tend to fall on your side regarding dressing changes. There is almost no wound in the world that is best served with daily dressing changes. The more the wound bed is disturbed and exposed to air, the longer it will take to heal. Best practice is to tailor the treatment to the type of wound, type of exudate (if any), or need for supplemental moisture, and find a dressing that meets the needs of the wound with expected changes every 3-5 days.

Hanging Wet to Dry Dressings Out to Dry is a great article that debunks the myth of daily dressing changes and their cost to both the patient and the agency. Print it out, give it to the LPN, and address her insubordination by changing the plan of care that *you* formulated without discussing it with you first. Make sure your supervisor is aware of the situation.

[HmarieD]

KateRN -

Just when I think, oh I'll respond to that with this, I see the next post in which you have already done so, and probably more effectively than I would have! Just wanted to let you know I respect your opinion and it's always a pleasure to read your posts.

[spejsa]

Kate,

So, the patient finally got to the surgeon for a follow up and now the LPN says that the dressings are BID????

Stacey

[KateRN1]

Awww, shucks. :loveya:

Not sure why the dressings are BID, unless it's someone who doesn't have a clue about wound care. Maybe the LPN is trying to increase her visits? The HH agency doesn't get paid per visit, so that actually decreases their profit margin and is not in the agency's best financial interest. Sounds like people at your agency could use a good wound care course. There are rare occasions where frequent dressing changes are a good idea, but they are rare and not often encountered in home care. Every time you disturb that wound bed, you're slowing the healing process. You can't get good granulation tissue if you're ripping it out twice a day. Good luck with your new agency.

[spejsa]

I know!! I don't know why the dressings would be BID either. All I can think of is this man hadn't been to the wound clinic this whole time since yesterday. So, it was the first time they saw the wound and they are starting at the bottom... Then, they will increase, etc. The orders also said 'TEACHING FAMILY DRESSING CHANGES'.