Don't you control when to d/c the pt's? Are they Medicare? If medicare and they aren't home, that would be fraud to keep them open, and I won't do that, and put myself in the path of fraud charges for anybody, pt, doc, or agency.
If not medicare, and don't have to be homebound, then I document all attempts to visit in the progrss notes. ON what I decide will be my final attempt, I usually go by the 3 strikes and you're out policy, b/c we don't have a policy, (policy? who needs policies, why not every nurse do it differently? Consistency? Who needs that??) ON the last try, I slip a progress note under the door, it will say something to this effect...
You have not been home for a nursing visit at the agreed upon time for 3 out of the last 3 attempts. When you agree to an appointment, and are not home, this takes away a visit from another client who is home, and needs nursing care. I need to hear from you by __________ (I usually give them 2 -3 days.) If I do not hear from you by that time, you will be discharged from the agency.
Supervisor Shesa Nurse Phone xxx-xxx-xxxx"
Then, on the said date, I chaeck my voice mail at the end of the day, if I or my supervisor has not heard from them by then, I d/c them. Now, if it is someone who is frail, I will call the emergency contact person and inquire as to the status of the person, maybe they are in the hospital, or away at a funeral out of town, or have a good reason for missing appt's. If so, that is a whole other kettle of fish.
I had a young MS pt, newly diagnosed w severe renal HTN, and severe HTN 200/120, needed avonex inj, and to be instructed on glucometer for steroid-induced DM. I got 2 visits in out of 9 attempts. I did go the extra mile for him, b/c I believed his sob story...until his cousin blew his stack and flat out said, he is the most irresponsible person and he is sick of having to account for him, don't call again! OK---> D/C.
I write the note on the paper that makes copies, so I have a copy for the chart. When I get back to the office, I xerox it, and fax the note, and a cover letter to the doc, so he will know status.
They tried to re-refer Mr. Irresponsible, but we couldn't find him again on the first visit, and that was that for him, repeat offenders get one strike, if not still in the hospital. We have precious little staff to see so many, we can utilize out resources in a much better way than to waste time and milegae on people who aren't concerned enough about their own health to be present for a visit. IF the agency doesn't reimburse for time, I would flat out refuse to waste time going to these no-shows.
A lot of the problem, I truly believe is when the case is opened, pt's aren't truly assessed for exactly what their needs will be. If they can get out to social events, they can take themselves to the doctor's office as far as I am concerned. Also, people need to start really asking pt's on Medicare, would you describe yourself as homebound? For example, do you do your own shopping? Do you drive? Do you go to the senior center? Luncheon w friends?
Had a sweet lady today, went out and couldn't believe she was my pt, looked too young for medicare! She had cellulitits of BLE, and needed wound care. She had just gotten out of the shower, and said, I was going to do the drssing myself, but I'll let you since you're here. I asked if she could reach, and she did so w ease. I did one leg, she did the other w a tad bit of help w the kling from her hubby. OK, she shops, goes out, and said "My dr wants me to go for some outpt PT" OK, let me explain what medicare requires in order for you to recieve home care. She was actually glad, b/c she didn't want to be inconvenienced by waiting around for a nurse to visit, not exactly her words, but she meant it, in a nice way, essentially. So, I made it a SN eval visit only. Called the doc and said she's not homebound, I can't keep her case open, please send her a rx for supplies.
If the person openeing the case explained that they are expected to be home for visits, and if your agency put a statement to that effect in their brochure, maybe it would help. We have all just decided w alll the paperwork we have to do, we are not wasting one precious moment on people who don't need us. At least I won't. Another way to catch your medicaid non-homebound pt at home is to visit when their PCA is scheduled, they rarely miss their PCA's visit. I have 100% success by doing that.