Inappropriate referrals/admits (Whining!)

  1. I am curious about how other agencies handle this.

    What I mean is, daily or bid dressings with no caregiver in the home. Now I can certainly understand if the referral came from a hospital far away, BUT, we have Liaisons in all the major four hospitals, and one who rotates through the local rehabs, so WHY are we still getting these referrals?? What exactly are these Liaisons doing? Just copying orders? Don't they have some responsibility to ask the pt if they have a willing CG in the home??

    And our intake dept! When you have the doc's office ON THE PHONE, is it too freaking much to ask if the pt is homebound, has a willing CG, or for a freaking emergency contact number when there is NO PHONE????


    So, what happens, we go out, and the CG suddenly decides they can't do this care, or there was never a willing CG, but in order to assess the wound, we have to do hands on and do wound care. My agency feels if we take VS or touch the pt hands on, we buy the case. I say BULL! We but it temporarily, until we cab give notice that services will end on such and such a date, and tel the doc pt has to make other arrangements!

    I opened several iffy cases, one case there was even, in the past, a contract w the CG, which he never kept. Was any of this info passed onto intake? WHY do we take these cases back?? I opened it, taking pt on her word that CG would assist, not knowing APS was already following pt and she was due to be evicted from her apt. She told me she was "thinking about moving." How am I supposed to know the first time I ever saw her she was a complete manipulative Liar??

    Next thing you know, I am reamed for opening this case! And we are getting inserved up the rear about when not to open cases, etc...

    So, today, go out for a BID wound care, BAD area, roaches in home, and for some reason a ton of flies (I figured the maggots will be good for the wound) and CG decides she can't handle it. I immediately tell pt, in that case I have to clear admit w supervisor. I call her, as per inservice, I have to sit and wait in roach motel till sfter multiple phone calls btw her and 2 admins, they decided IF this, and then THAT, and IF this and doctor documents CG can be I in this wound care, then we can take the case. I'm like WAIT JUST A MINUTE, that is THE most wishy-washy crap I have ever heard. This is it, you tell me yes or no, right now, based on what I told you, do we take this case or not? Finally, they decided YES, since it was Caid and at least supplies are better covered.

    Un believeable!

    I mean our first problem is clearly communications, somehow supervisors, who are well-aware of problem cases, do not notify intake we don't want them back. I have kvetched on end about this to NRSKaren, and she even sent me great info which I passed on to them, and still it is a problem.

    This particular case I can't blame on intake b/c we got it on the weekend, so I frankly blame the supervisor. She should have called the D?C planner and confirmed CG was available. Tho, so many people seem to know if they say yes intialy, they will be d/c and get the services anyway b/c agency bought the problem by accepting the referral.

    I know Karen's policies, they are organized and logical, but how does everyone else handle this? I am so freaking aggravated, I am ready to bail to the next homecare agency! Also applied to a weekend sup job in south jersey, but I think the spot was filled already, latest ad didn't have position posted.

    I am beginning to HATE home health.

    Seems like every time a case costs the agency any money, it's the nurses fault! It's getting really old.
  2. Visit hoolahan profile page

    About hoolahan

    Joined: Dec '99; Posts: 3,786; Likes: 129
    Quality Nurse & Home Health Nurse


  3. by   renerian
    Hoolahan I have worked for several different agencies that did it differently. I had one that said if you touch them you've taken the case. The later one said you are to have a frank discussion with the client that Medicare does not cover infinite visits and that someone needs to be taught dressings. We talk about the finite and predictable end to bid or daily visits. WE talk about private pay. We talked about wounds only being cared for as long as their was progress which for statis ulcers most of the time were never going to heal. WE took the case temporarily under the premise in a short time someone would be located. If no one was we documented heavily the option to private pay with us or another agency and we would make a referral to that agency, have some one come out for a joint meeting with the client, us and the new private pay agency. If they refused we were covered as it was documented you educated the client/family on all the above and the ball was put in their court and they refused care. If it was impossible to do so due to some mental health issues a social worker was also consulted to educate someone on other living situation options or to help the client get on medicaid or see if they qualified.

    Does any of this help?

    In my current job I get referrals from DR. offices and everyone is in a huge hurry and only wants to give me a name and number. This is okay for me as long as the person is competent or healthy enough to respond to lots of questions.

    Many of my referrals come from home health RN,s. I devised for them a one page faxed referral which most of the like. I get referrals via fax at all hours of the day. I get incontinence items for Medicaid/private pay clients.

  4. by   passing thru
    You sound so efficient rene.
    And hool, I would tell them to cram it, but someone has to help these poor patients at home. It's not their fault our health system is in the pathetic condition it is.

    Efficiency is a marvelous tool that few possess. I
    work in the most inefficent hospital I've ever seen.

    Just today, I was making comparisons of hospitals and doctors.
    There is a reason why some are great, are "world class."

    It is efficiency. How you aspire to delivering quality care when you can't even make a comprehensive and enforceable policy for one simple nursing intervention?
    Where I am, each nurse wants to individually interpret it, perform it , and document it "their way."
  5. by   hoolahan
    Yes, efficiency is something my agency does NOT seem to get. Another forgeign concept is consistency!

    I am also sick of inservices where the finger is pointed at the "per diem" or weekend staff. Hello, most of us used to be FT there.

    TO me quite honestly, intake can make or break your agency. Why does it rest soley on the shoulders of the nurses in the field?? A little help from square one, ESPECIALLT if our Liaison's are obtaining the referrals, would be appreciated.

    I was a weekend supervisor, and I actualy READ the referrals and if I had questions, I called the d/c planner and demanded, nicely, more info, if I didn't get it, they were informed we could not accomodate them, amazingly, info was found. So, I KNOW it can be done better, it takes energy and committment, and work!!

    Renerian, everything you say makes perfect sense, and I do not understand why it has to be such a huge issue to open a difficult case unless the pt truly is unsafe in the home. For every bid wound or ANY would I have opened where there is no CG, I automatically refer to a MSW from SOC!! The problem is, she is lazy too. And when I see her in the halway, she will make a stupid remark like, "Do you understand we don't have to accept a case for homecare in this situation?" DUH!!! Do YOU understand hospitals d/c pt because we accept responsibility for their disposition??? And if they knew there were so many issues, they wouldn't have nothered to refer to us, but placed the pt in a SNF from day one???!!! Why not simply make a policy, NO CG, no referral...period. The other agency I worked for stated NO evening visits and NO BID wounds, no exceptions!!

    I swear, I am ready to ask if I can work for LPN salary and not have to open any new cases any more!

    Funny, when they have a "difficult case" they want to give it to me, (yeah I know, it's BS for me being the only sucker available usually) but God forbid I open the difficult case, I am criticized up and down.

    Oh State of PA, please RUSH me my date to take the manicure licensing exam so I can leave nursing as soon as possible!!!

    I just want to add one more rant, do you know how bad it feels to have to have these conversations, by yourself, with a vulnerable pt who lives with multiple people who cannot help her out, and it makes her feel like shyt?? That makes me feel like shyt. Home Health has become infected with the coporate fever resistant to all decency, and it is no longer about serving the people, it is about the almighty dollar. That is my sign to get the heck out.

    I think I have exhausted all possibilities in nursing specialities and I am sooooooo ready to throw in the towel. I am even thinking about cancelling wound school before I make my first payment. Do I really want to do this?? I have become jaded and cynical and I am even thinking about taking down my website which has been all about recruiting nurses to HH because it feels hypocritical right now. Working for a living SUCKS!!!!

    (Thanks for listening!)
  6. by   sphinx
    Last edit by sphinx on Jul 7, '03
  7. by   renerian
    Hoolahan I am sorry I know home health is hard. Do more with less time, no help and limited supplies. I have done dressings made of sanitary napkins before. I did not know you were going to take some wound care classes? Were you planning to contract with agencies per diem for wound care consulting or be a wound care specialist for your agency? One of the agencies Iworked for would not let per diem nurses do openings. Your right PPS has changed the face of home health.

    What would you like to do?

  8. by   CseMgr1
    How WELL I remember those days! Ran my butt off all over God's green acre, playing handmaiden to folks who were no more homebound than I was....while the people who really needed the services were left out in the cold. And I didn't DARE complain, lest I be told by some idiot in Management that my job "depended" on these visits.

    WHOSE job? Excuse me, but I think the first jobs to go when PPS came out was in upper and middle Management...
  9. by   hoolahan
    Hi Renerian! I was going to do independent consulting. Another nurse at our agency finished wound care school, and git her MSN, my program is not a masters program, I want no part of that nonsense, but anyway, she wanted to work w them to create a role for herself in the agency and we have no wound cert nurse, only a nurse who has been considered a specialist in it for many years and yes she is good, but not certified, when a real problem wound comes along, they hire a consultant.

    So, when she approached my agency, they told her, well you would have to carry a case load of about 30 wounds, and in no way wanted to let her develop a formulary or do inservcing, it was all about being a staff person. Well, thsat was not what she busted her butt in school for the last 3 years for at great expense!! Tyhat is how my agency takes care of it's staff!

    What do I want to do? Work independently. Seems like I am going to have to advertsie though. I am going for an interview next week for a weekend super job (I think I'd rather dish out shyt that take it, just kidding I don't dish out shyte!! ) and then I will supplement with a job in the nail salon, serriously. Hhhm, sitb in an air-conditioned salon taking care of feet and hands, or trudging through coakroaches and sweltering heat becoming dehydrapted to take care of feet and the rest??

    I'm sorry to be such a downer.

    Today was actually a great day, did 3 new admits, and they al were quite sick and actually needed a nurse!!

    Tomorrow I start the day in roach and fly land!
  10. by   LoisJean
    Oh, Hoolie! This is all my fault for not being electronically near to you for these past weeks.

    I hope that by now you have popped your supervisor(s) in the snoot(s) and reminded them that all incompetent, shortsighted and snotty nurses go to Hades in a handbasket. Girl, what you've described above is the way it is here, too. What a mess health care is in....from the hospitals to the homes. No nurse is to blame for this mess--but, we're all responsible!

    Don't you know, this is why so very many good and deserving nurses are giving their employers the third finger up. You'd best get over to the Entrepreneur Forum--it'll make you feel better. Foot Care, sweetie...your own money, your own schedule, your own peace of mind; work it any way you like--nursing service, pedicure service or mix the two together. Advertise. Do it. Do it. Do it. I have selected the following date: Tuesday, December 16th, 2003. This is the day you will be on your own. There, now doesn't that feel better? you, hoolie

    Check your email........
    Lois Jean
  11. by   NRSKarenRN

    You just need ME to come over to tour VNA and shake up the intake department!

    I've been TURNING DOWN CASES for two weeks now due to lack of staff in Philadelphia and the FT RN's doing laptop training there (not MEDICARE of course).

    Today I called our NJ office to see if "OK to accept an indefinate daily injection for osteoporosis med" for patient who lives alone and is legally blind ---has Medicare and Medicaid. Was told to accept the caseby the administrator---at least I got the heads up or otherwise my head on a platter.
    Two hrs later CEO told me I need to have a meeting with her and this administrator tomorrow cause "NJ is tired of getting late auths". Sometimes you win, sometimes you loose.
  12. by   hoolahan
    It's getting scary out there isn't it???