Custodial or Skilled?

[JennyHHRN]

I hope I don't get banned from asking too many questions! Here's another situation I'm grappling with:

Patient has been on service for a year for Foley Cath Maintenance (neurogenic bladder), right sided hemiplegia late effects CVA from 2001. Has visiting physician that orders Physical therapy for home exercise program. Therapy goes in gets patient going with PTA's assisting HEP. Family has paid caregivers (taught them HEP). Patient gets d/c'd from therapy.

1 month post therapy d/c, physician orders therapy again, states patient has declined needs new evaluation and new HEP. We go through the whole thing again and then therapy d/c's.

Now it is 3 months since patient was d/c'ed from PT and doctor is ordering it again. Wife begs for therapy, she states once patient is d/c'ed from hh therapy, paid caregiver just can't assist in HEP the way HH staff does and patient gets weaker. She and the physician want to continue this on and off therapy process forever.

Is there a limit to how many times therapy can come in and treat the patient? He will always be on HH because of Foley Cath, definitely homebound, can barely get out of w/c, needs assist with any ambulation.

I worry that once you teach paid caregivers an HEP it becomes a custodial case. The physician argues that each time he orders PT it is because the patient has experienced a decline in functional status, so therefore patient meets skilled therapy criteria, regardless of how many times he has had therapy in the past.

I'm soo torn. ?????

[NRSKarenRN, BSN, RN]

Is there a limit to how many times therapy can come in and treat the patient? He will always be on HH because of Foley Cath, definitely homebound, can barely get out of w/c, needs assist with any ambulation.

The physician argues that each time he orders PT it is because the patient has experienced a decline in functional status, so therefore patient meets skilled therapy criteria, regardless of how many times he has had therapy in the past.

No limit on the amount of time pt can receive PT. Criteria as stated by physician is correct: pt has had decline in functional status from previous discharge. As long as that is documented in notes, Medicare will pay for homebound patient. Upon restarting Therapy, once patient has plateaued, therapy will be discontinued. I'd also consider OT Eval for caregiver education for this client.

Always keep in mind for your long term patients, point they are declining in functional abilities, time to discuss with PCP need for PT/OT/ST where indicated.

[Quietstorm1234]

If the pt has a decline in their status and they have rehab potential, PT can go back as long as the MD orders it.

[caliotter3]

I've often wondered about the need for skilled care rather than custodial care. In some cases I've been very limited in my duties for the pt so I have to remind myself that their condition calls for homebound status and that is the reason skilled nurses are there.