A ? for Home Health Nurses

[VivaLasViejas]

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.

[weetziebat]

it has to do with the money. owners want the resident to stay due the money.

of course. that's always what it all comes down to, isn't it?

[homehealth43130]

It has to do with what is in the basic contract that the client has with the ALF. Medicare's position is that if it is in the contract that the ALF provides nursing or aide services then home care cannot provide because it is not reasonable and necessary as they are already paying someone for thoes services. Since each ALF offers different packages, each client must be assessed on an individual basis as to whether home care can provide services or not. All the rules for Medicare home care must be followed i.e. homebound. The agency that admitted him should have issued him a notice of noncoverage before discharge giving him the option of appealing to the

QIO (assuming he is on medicare). He always has the right to appeal any of his care or care he thinks he should have received. The information for the omnibudsman should have been given to him at start of care with numbers for the surveying body to report complaints. He must make these complaints, but should have the information in his admission paperwork. Hope this helps.

[VivaLasViejas, ASN, RN]

It has to do with what is in the basic contract that the client has with the ALF. Medicare's position is that if it is in the contract that the ALF provides nursing or aide services then home care cannot provide because it is not reasonable and necessary as they are already paying someone for thoes services. Since each ALF offers different packages, each client must be assessed on an individual basis as to whether home care can provide services or not. All the rules for Medicare home care must be followed i.e. homebound. The agency that admitted him should have issued him a notice of noncoverage before discharge giving him the option of appealing to the

QIO (assuming he is on medicare). He always has the right to appeal any of his care or care he thinks he should have received. The information for the omnibudsman should have been given to him at start of care with numbers for the surveying body to report complaints. He must make these complaints, but should have the information in his admission paperwork. Hope this helps.

That does help! Thank you!!!

[cookie102]

under medicare and PPS when a patient goes out patient for PT/OT and still requires nursing the HH agency must pay for the outpt treatments. if the patient can continue with the PT and OT at home (and ALF's are considered home) until no nursing is needed medicare will pay the HH agency. if this person would benefit more from out pt perhaps the PT can come up with a wound modality they could do. hope that helps