Home Health and expectations

  1. I have been an RN for over 20 years now. I have done a variety of things in the nursing fields from medsurg, to orthopedics, to ER. About 7 years ago in started with a Home Health agency.
    When I started my agency was non-profit, but last year we became for profit, and even though we were told it would he business as usual, it is NOT. Not only that, but our pay was cut. I'm not kidding, it was cut. The boss doesnt see it that way but my paycheck does. I can explain later or some other time, but.....
    Needless to say, anyone that is an RN wants to truly help people. Formerly being in the hospital setting Inwas used to treating either acute injuries or illnesses, or exacerbations of chronic ones.
    Make no mistakes it's not that I thought Home Health would be easy, or easier per se. But some of the most shocking things I have found are the levels of expectations that patients and families have, about what we do, and will do, along with the level of non-complaince, and the amount of patients and family members that are defendant upon, and have no intentions of NOT being dependent upon the services of Hone Health agencies, and health care in general. It's a staggering number of people, and although the reasons and backgrounds vary, its rich people and poor people alike.
    Our job is to try to promote independence. A liberal politically as I am, I cannot help but be in utter shock at the amount of people that have absolutely no intentions of being independent. None whatsoever.
    There are a staggering number of people who will not even do a simple thing, no matter the amount of education, like take thier medications, or skin care, etc. They want someone else to do it family members too. How many Home Health RN's can tell me they haven't seen lazy family members that will not do simple things for thier loved knees they live with that will help to promote thier health. I had a patient rehospitilaized a few weeks ago for infection in a stage 4 sacral wound. Each visit (3xweekly) his diaper and bed were soaked in urine and feces. I mean, the bed, head to toe. They wouldn't turn him. No dressing changes. Wanted US to do it all. WE should be healing him.
    I've had patients I have seen for wound care, flat out tell me they didnt want to hear about what they should be eating, or having there blood sugars under control, "JUST DO THE DAMNED DRESSING CHANGE". I would calmly try to explain that doing dressing changes IS part of the plan of care but it isnt what Medicare pays for, it's the assessment, teaching and education.
    I went to do a wound vac last night because I was on call. After already having a VERY long day of seeing 8 patients in 2 different states, I was told the patient was discharging around 3 or 4 PM, and that the actual SOC and IV antibiotics would he done the next day by knee of the weekend nurses, I was to go and place the wound Vac.
    Depending on the wound and other factors, I can usually do such a visit within an hour. Less maybe. I'm pretty good with wound vacs, I was trained by someone who used to work at KCI.
    The patient was sitting in an electric wheelchair in the living room and had to be transferred via hoyer to the bed. The wife did absolutely nothing. Refused to. Said I am the healthcare worker, I am to do it. He had feces in his diaper, so after being transferred had to be cleaned. Large scaral stage 4, approximately 10cmx9cmx5cm. HUGE. Looked good as far as it was beefy red. So, while the wound was being soaked with Dakins for 30 mins (wife insisted, although that was a previous order I could see the new wound vac orders, I felt, superseded those), I went over the consent forms, etc, and what services were to be offered. SN, PT, and OT. She asked how many visits for PT and OT were ordered. I told her only one is ordered, they evals, they will come do an evaluation with him and you and go fro. There. She then goes on to explain how he got them daily in the rehab facility and that's what she expects to continue. I told her that is not realistic, and that thier job, and ours is to promote independence, not to do FOR him or you, but OT will instruct how to safely transfer him in the home. No, no, no. She said. They should be coming and doing it .
    I also exained that tomorrow (Saturday) an RN will come out to do the actual SOC and instruct her on how to do the IV antibiotic meds (one push, and two by gravity I believe, via a PICC in Left arm).
    I'm not a nurse. YOU guys are supposed to be giving his meds DAILY. It's YOUR job, and the Dr said he would send someone out to do it.
    2 hours later I finally left. I will get ONE unit, or approximately $36, and I still have to chart everything. People complaining wanting a $15 minimum wage, and I will get less than $13 per hour for this visit with this patient, who unfortunately has to move with a spouse who refuses to do what is needed (she was very upset when I recommend a coccyx cushion in his wheelchair to help offload pressure). Just heal the wound. Put the wound vac on.
    Lovley. Wants a wound to heal, but doesnt want to relieve pressure. What are the chances of that, considering he will likley be kn the wheelchair all day.

    Anyhow, that's just one story, of HUNDREDS I could tell you. Maybe more.

    People want free services, free things. Expect me to bring the chic, diapers, etc.

    Otherwise capable people that refuse to set up thier own pillboxes.

    I discharged a patient Thursday who refused to check her own blood sugars, despite being on Insulin. Said it's just something she doesnt do, and has no intention of doing. She can walk, but has had multiple toes amputated, due to diabetes. I had had enough. I DC her from SN. She will still get PT for another week or 2, but I think it's a waste. She sits around watching TV most of the day. Her and her fiance actually wanted me to make her Dr appointments FOR her. I'm a grown adult, I have not had another person make my Dr appointments for me since I was a child. Ibwas on hold 3 separate times for almost 2 hours to get her a Dr appointment, despite the fact that her and fiance were told to this by the SOC nurse.
    I'm pretty sure I have patients who keep themselves from getting better or wounds healing, simlmy because they want me to come see them.

    Its just getting tougher and tougher and OASIS isnt getting any better, Dr offices. Hospitals, and clinics wont return calls.

    I truly enjoy helping peo ppl, but SO many dont want us to help them become independent. They want US to do FOR them. Not ALL, to be sure. Some do cooparate, are appreciative of the help and education, and assistance in returning to or becoming more independent. But enough are like this, that I feel like it's a real problem in our society.

    I don't know how we survive as a country.

    I may be close to the end of my rope on the Home Health gig, fed up with an agency that runs on the cheap and I have to use my own band aids on patients and I'm not likley to get a raise (havent had one for over 3 years), but our health care crisis in America has multiple reasons. Peoples lack of willingness to do anything for themselves is one of them..

    Having recently lost a friend who had a neurological disease, and couldnt move or feed himself for the last year, and just died a few weeks ago, I'm amazed at the amount of people that CAN do all of these things but wont. I thought it was silly, when I was in the hospital and I'd walk an able bodied patient to the bathroom and they would lean against the wall and want me to wipe thier ass. Some people cant, I get it. But far too many simply wont.
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    About BrianLee73

    Joined: Sep '14; Posts: 2; Likes: 4

    3 Comments

  3. by   amoLucia
    (((HUGS)))

    I can't say anything but 'wow' to you and hold out good thoughts and wishes for you.
  4. by   KelRN215
    For the patient who you find soiled from head to toe every time you go out to see him- Adult Protective Services needs to be called immediately.

    I don't disbelieve that a doctor told the wife of the IV antibiotic patient that a nurse would come out to administer the medications. I was an infusion liaison for 3 years and the doctors frequently did tell families that. Then the Case Manager and I would have to explain that that's not how it works and if you want to take your child home on IV antibiotics, you need to learn to administer them and care for the PICC.

    Also it sounds like a large number of these patients should have Home Health Aides or PCAs (not sure if your state has that) in addition to the skilled services they are receiving.
  5. by   Neats
    I can tell you as a case manager working for an TPA insurance company if you submit that documentation and the time you spent I would approve the extra time initially. I see billing that is not accurate and would bill way more than what organizations do and sometimes I see billing for really what is custodial care (non skilled nursing).

    Most of the time the care the patient needs is custodial care and that is not covered by insurance but skilled nursing services are. Think can you teach a person to do this? Spiking a bag of IV solution is easy and you can teach family... wound vac not so much, complex wound care is skilled in that we measure, we look for tunneling but a knee replacement and over size dressing change with NS irrigation you can teach this to family as well.

    G0162 is a RN home Health code designed for delivery of management and evaluation of plan of care every 15 mins this requires the RN to ensure essential non skilled care achieve its purpose in the home-it is based on the patient underlying condition/complication. You can bill for this and document your time spent "achieving a non-skilled care how you managed this with the spouse and how long the discuss was. (think what you are doing much like a NA-C. would do)

    G0164 is a code for licensed nurse educating patient/family member in home health every 15 mins. Again document your time spent just like the PT/OT.

    G0154 for Licensed nurse direct skilled nursing services (think hands on patient) and every 15 min increments

    The above codes are set forth from CMS and there is a reason for these code changes. CMS wants to know really what goes on in the home. They are trying very hard to get a break down with common identifiers thus the need for RN verses LPN and education, direct skill care needs...It is vitally important nurses document their time exactly. You can have more than one of those codes for a visit and more than 1 unit so to speak. Who ever your coder is must be on top of those codes and if questions arise then I encourage you to get an answer from CMS not from a coder who is looking at it their way (I am not saying coders are bad by all means, just want to get that info straight from the horses mouth) There are other codes that are used for a home "visit" I do not like those codes because it does not show the true visit the above codes can and do.


    The documentation I see on a daily basis is not really easily understood for billing purposes. I would like to see a 15 increment fill in the blank for what you are doing, I am way more than willing to give extra units. So when you were changing the patient say you started at 1330 the 15 time increments would look like this
    1330-Assisting patient with incontinent care of Bowel and bladder using hoyer lift as assistance
    1345-Continue with patient incontinent care needs with hoyer lift
    1400-Patient placed in recliner with replacement clean incontinent product-patient resting comfortable
    1401-Started with wound dressing change
    1415-Wound vac dressing change continued
    1430 Wound vac dressing change continued
    1445 Wound vac dressing change continued
    1506 Wound vac dressing change completed and patient states it feels like it is fitting good, no C/O pain but a little pressure.
    The total units for the G0154 would be 5 units. You can clearly see looking at times- the direct patient care.

    You can bill for G0154 AND G0164 you just have to document this. You can bill extra units as well so if your G0154 was 1.5 hours you would bill 6 units. and Your G0164 would be say 3 units because you more than likely spent at least 45 mins education/clarifying with the patient/spouse.

    This is fair and clearly shows what services you provided. That is what I am looking for and that is what I will approve as long as the documentation is there.

    When it comes to custodial care we usually allow for a few visits for education and then maybe an extra one for reinforcement. Ultimately I have discussions with the patient and family about what is skilled and what is covered from the insurance stand point. I too find that in the home health environment family and patient have the expectation of having the nurse come in and do everything for them.

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