Medicare and Skilled needs - page 2

by spejsa 6,861 Views | 18 Comments

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... Read More


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    Why do you want to discharge that patient? Wound care is certainly a skilled need, especially when the caregiver refuses to do it. I take issue with the daily part, though, as most wounds do not need daily care and actually will not heal due to disturbance of the wound bed. Consult with an WOCN if you have one available. The patient doesn't get discharged just for missing a few doctor visits. As long as you still have a doc claiming the patient and willing to sign the 485, what's the problem? And why hasn't the patient filled the rx? Is it a money issue? An inability to get to the pharmacy issue? Other issue? Look into the reasons and work from there.

    Sounds like a social worker is in order for this patient.
    HmarieD likes this.
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    A social worker is in order. Remember, KateRN1, I am new to home health. This particular patient has a history of drug abuse. He told the LPN last week that he has had no pain meds since DC from hospital as his family took his pain pills. I thought that we had to have somebody in the home to teach and that was the basis of home health. So, we can go eternally on daily visits? The problem with my agency is... We can make daily but the weekends are a problem b/c all of us are in different areas.
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    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?
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    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...
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    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.
    Karen A and HmarieD like this.
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    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.
    annaedRN likes this.
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    Kate,

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

    Stacey
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    Awww, shucks.

    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.
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    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'.


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