Case manager deciding when to discharge rather than the RN seeing the patient?

[HeadingWest]

I recently switched agencies, and I am going on two months at the new one. Initially everything about the new agency was better, but cracks are starting to appear.

I was added on to take care of 3 little stage 2 decubs in a pt's gluteal cleft. The pt is in an assisted living, chairbound, and non-compliant with any kind of offloading/position changes. My orders were for dressing changes 3 times per week, so I put her down for 2wk1, 3wk4 unsure how long it would take for her to heal. Three weeks later everything looks great, and I'm thinking to myself "Awesome! We got you healed up faster than I thought, so time to D/C."

I'm at case conference the day before I'm going to D/C when we are told that there are too many people with discharges coming up, so we need to try and extend some for a few more weeks. This included the patient I was going to D/C.

My CM told me that I needed to get an additional order of 1wk4 for med management, but I cannot find any justification for this. I have no problem with adding on some extra weekly visits for med management to ensure that it wasn't a fluke when a pt/caregiver set up meds correctly/was compliant for a week, but this pt is medically stable, PT/OT have her at max ability, her wounds are healed, the staff at the assisted living administers medications, she cannot retain any teaching that I could do, and she receives weekly NP visits from her doc's office. I was 4 visits short of my initial frequency, and my CM has since added on the additional 4 without either of us receiving orders. "Assessment completed. Pt stable without complaints. Wounds healed" isn't going to cut it for 8 more visits.

I'm being told that too many early discharges raises flags when the company is audited, but this seems ridiculous. Not only that, my CM is telling that I don't have enough initial visits for other people. I've found that some people progress much faster than anticipated while others take longer, and that my initial frequency is something flexible that changes based on the needs and abilities of my patients rather than a hard line that must be adhered to.

[jmn126]

I actually think it is a good idea to continue to see a pt 1w3-4 after wounds healed just to make sure it stays that way and. Family/staff continuing to follow plan. Just my opinion

[HeadingWest]

I agree, and that is what am doing now. I was told specifically by my case manager that I needed to add visits for med management and that is what I had an issue with. I'm still learning how everything works in home health and talked through the issue with my director of clinical services. I'm used to making visits for observation/assessment of chronic conditions, but I guess I've never looked at risk for skin breakdown the same way. It makes sense to me now, and if they had presented it that way instead I doubt I would have felt the same way. I've learned something that will allow me take better care of my patients which is always good in my book.

[AnnemRN]

If the wounds are healed and there are no other problems the patient should be discharged. Discharge instructions should include pressure ulcer prevention and if wounds reoccur then patient can be readmitted to home health. Patients should not be kept on service just to make sure skin doesn't break down again.

[tktjRN]

It depends on the patient and the risk for skin breakdown. If the patient is chair bound, bed bound or has been admitted to your agency more then once, for wound care, I would keep them on O&A for 1wk3. If a patient is ambulating, able to change positions Independently and appetite is good, I would dc the day the wound closes. Medicare does frown on O&A after wound closure so documentation must be thorough on why you're continuing to see patient.

[BabaLouRN]

I actually have patients that would HOPE for another wound just to keep the nurse visits to "take care of me"