A ? for Home Health Nurses

[VivaLasViejas, ASN, RN]

I have a resident in my 42-apartment assisted living facility (ALF) who was in a log truck-vs.-bicycle collision over a year ago that nearly ended his life. He has had multiple surgeries, skin grafts, traction, etc. as well as a few CVAs and an MI during the first few weeks after the accident. On top of that, he had MRSA, C. diff, pneumocystis, and VRE during repeated hospitalizations. He's doing well for a 73-year-old who's been through all this, but he was left with a number of deficits requiring multiple therapies.

He's doing all his PT/OT and hand therapies on an outpatient basis now, but recently several of his wounds opened up again and he acquired new ones just teeming with MRSA, despite the 3x/week wound care treatments I was doing. I called his MD for a new wound consult since I was fearful that the infection could go systemic again, but could not get the WOCNs at the local hospitals to even call me back because, as their office managers told me, they were booked solid and could not possibly take on my resident. Again, he is able to travel locally, but what are you supposed to do when you have orders for a wound consult on someone with wounds that are full of staph and getting worse by the day, and no one can see him? So when one of the hospital people suggested calling home health, I jumped on it even though they'd discharged him a few weeks before due to his status change from 'homebound' to non-homebound.

They came out, changed his treatments and got him on antibiotics, and came in 3x/week like they had before. Then yesterday I got a very rude phone call from the home health nurse, who dropped this patient like a hot potato and refused to return to discharge him (again) or leave me written instructions. She wouldn't even call him to let him know why she could no longer work with him! Seems there is a Medicare regulation prohibiting home health agencies from serving patients who are technically outpatients; in fact, as the supervisor said this morning when I called to complain, this particular agency has been cited before for doing so.

OK, it might have been nice for the HH nurse to explain this to both the resident and me so that we would understand why she was dropping him so abruptly, but I guess because I'm a dumb ALF nurse who doesn't know all the rules and regulations of a job I've never even worked, my resident isn't worth the time it would take for her to do so. What was I supposed to do, let the wounds continue to deteriorate until he went septic? What I want to know now is WHY the rules make it impossible for someone like him to get the care he needs, and what he's supposed to do when he can't get to a wound specialist? Frankly, most ALFs don't even have a fulltime nurse (I'm lucky in that I'm there 32 hours a week); how is complex wound care supposed to be done in the time ALF nurses are allotted?

If someone who knows the rhymes and reasons of this alleged rule could explain to me why it's that way, and what the alternatives are available for someone like my resident, I'd appreciate it. As it is now, I'm teaching the family how to clean and dress the different wounds (lucky us, they are all colonized by different bacteria:uhoh3: ), and I've delegated a caregiver for the task. Plus, I've made up my mind that it simply has to be a top priority for me to oversee and carefully monitor the wounds, regardless of how long they take to heal. But wound care is NOT my area of expertise, and I know my limitations---when something is beyond my skill, it's time to call in the experts. Only it seems that thanks to some technicality, there is no access to those experts, and I fear for my resident's long-term prognosis if those wounds get out of my control again.

[VivaLasViejas, ASN, RN]

Anybody out there who can answer this? Please?

[Jo Dirt]

Why can't you take him to the emergency room? It seems like an emergency.

[VivaLasViejas, ASN, RN]

He needs ongoing wound care, and will likely need it on a long-term basis because his skin has been grafted in so many places, and it tears with any provocation or NO provocation. I'm forever playing catch-up, because whenever one wound heals, two will appear to take its place. The man really needs daily skin checks and a minimum of 4-5x/week wound care, but since we are an ALF, we need outside assistance to provide intensive wound services.

As the only licensed person for 43 residents, I have neither the time nor the skills required to deal with such complicated skin issues as this resident has. It's almost a shame that he's not appropriate for SNF, because he could get MUCH better skin care there; however, he is otherwise A&Ox3 and in decent physical shape, and he certainly is too functional for ICF. I still would like an explanation of the Medicare regulations which were cited as the reason for home health services being discontinued, and what other options there might be for obtaining the skilled wound care he needs. Dutchgirl?? Dianah?? Jnette? Anyone??

[renerian, BSN, RN]

I will take a shot at this even though I feel very bad for this person. If he is not homebound (Medicare) he does not quailify for care no matter what. I do believe he needs more than intermittent care such as an ALF. He sounds like he needs SNF instead after a complete evaluation by a physician. Document all of that type of information. Will the house Dr. recommend a transfer to another facility that can meet his needs? I am guessing Medicare is not his primary pay source? Is Medicaid?

renerian

[weetziebat]

O.K. now I'm confused too. Marla, in our facility the nurses are not allowed to care for wounds of any kind. We do no dressing changes. These all must be done by Home Health. They come in ~3 times a week for as long as it takes for the wounds to heal. Personally, I love it cause wound care is not my area of expertise either and I have so many other things to do, its a lifesaver to have HH come in. But I wonder why the difference? Hmmmm....

[Nascar nurse, ASN, RN]

I am a RN in LTC on a skilled unit. Sounds to me like he is appropriate for a short term stay in LTC. I would think best course medically and financially would be to have a 3 day hospital stay to eval wounds and need for IV ABT? to clear infection - maybe debridement if appropriate.. then would qualify for SNF medicare and receive daily wound care until healed. At that time return to ALF.

[renerian, BSN, RN]

Nascar nurse, first let me say I like your avatar. Back to the topic, all good ideas for this nurse that posted the original topic.

renerian

[indigo girl]

I am a RN in LTC on a skilled unit. Sounds to me like he is appropriate for a short term stay in LTC. I would think best course medically and financially would be to have a 3 day hospital stay to eval wounds and need for IV ABT? to clear infection - maybe debridement if appropriate.. then would qualify for SNF medicare and receive daily wound care until healed. At that time return to ALF.

Absolutely agree that this is the only way to go!! He may be in a SNF for a long time though.

[HannasMom]

At the ALF I work at we have wound care nurses come in from Providence Home Health or Legacy to do the wound care three times each week. If the resident requires IV Antibiotics then they will either go to the hospital or a skilled care facility.

We are not allowed to do IV therapy in our facility. In fact ALF has so many gray areas it gets confusing. That is one reason I am considering going back to a skilled unit. Plus I can use my skills before they get rusty from non-use.

[weetziebat]

in fact alf has so many gray areas it gets confusing.

doesn't it though?!! do you have any idea why some nurses in alf's (like ours) can't do the wound care or i.v's, yet in marla's alf she has to do it? weird.

[HannasMom]

I'm always confused about the regulations for ALF. It seems they change all the time. I have had three different Wellness Directors (RN's) since I began working at my facility July 2005. They all have different ways to do things and change the rules every time.

I attended the 40 hour ALF Administrators Certification class and the regulations that our current nurse is instilling doesn't match the ALF model. UGH!!!

Someone told me it is because ALF is still a fairly newer concept and the rules and regs are still not crystal clear. Due to the fact that many residents stay even when they have wounds, conditions which clearly should be cared for in a ICF or SNF. It has to do with the money. Owners want the resident to stay due to the money.