Is this the norm?

[cmarn]

I just wanted to see if all agencies have similar issues...

I absolutely love Home Health. I feel like if we take time, we actually can help our patients. We have the time to sit with them in their own environment and educate them properly, monitor their conditions, troubleshoot...all things that aren't provided for in other environments. I feel strongly that we can make a difference. The issues that discourage me in my job are the following:

Schedules: Our nurses who have regular visits (pay-per-visit) turn in their schedules mid-week for the following week. Many nurses have 8-12 patients on these schedules, sometimes as many as 14. Our quota is 6 per day. Now, there are nurses who want a lot of paitents because of the money, but they are finishing at the same time of day as those who have 6 patients. What this tells me is that the quanity may be preventing us from providing quality. The purpose of our visits should never be to take vital signs, chart, and leave. If we are providing a skilled need then I feel its important to take the time to educate and assess. If we aren't doing this our patients don't need our service. The nurses who don't want more than 6-7 patients have complained but are usually told that their is no one to cover their patients. Even if there is someone to cover, this nurse is still case managing a ridiculous number of patients. Usually the schedulers are scrambling the day of the service to cover visits. Not sure why if these schedules were turned in days ahead of time. We continue to do new admissions regardless of how many patients we have.

I would imagine we would try to limit visits so that we can provide quality care to our patients. I would think that management would be monitoring the schedule and make necessary arrangements for this. If one nurse has too many new patients in a week I would hope they would consider her case load and reassign this patient.

Mileage: Currently we are getting less than 40 cents a mile. It takes a long time for it to be increased when gas is high, but it takes no time for them to deduct...

Qualifying patients: I feel strongly encouraged to accept patients that I do not feel are Home Health appropriate. Some examples: A patient who is not homebound who needs a one time foley dc. A patient from a doctor's office referral who has had HTN/diabetes for 25 years and manages their condition well but is looking for an aide.(referral says A/T disease process) A total hip who has been dc from SNF after a 2 month stay and is not taking Coumadin, no surgical wound. You get the picture. If I voice concern it is overlooked as me not wanting to do the work. And if I document honestly on the Oasis on functional status, I am asked to write notes as to why this patient is homeboud. (even though they might not be...) I am constantly hearing how "we need to meet quota"

Poor referral information:

When we get admissions to do in the a.m. we begin the tedious process. It usually takes 2 hours before we get our admissions and then we have to track down the patients. Some are still in the hospital, others have incorrect phone numbers and still others have no medication lists, etc. Without these things I feel it is difficult to provide quality care. How can you be sure the meds are correct if you don't have a list to compair to? Many, many, many patients are sent home from SNFs without discharge instructions, prescriptions for meds, newly dx diabetics without insulin, glucometers, syringes, etc. When we arrive we call the SNF and it takes days to reconcile for the patients. After I finally get out of the office in the morning, my admissions (in home) take at least 2 hours because of issues like this. Of course that doesn't include the paperwork in the office or follow-up doctors calls.

Poor coordination

Why do hospitals, SNFs, MDs give us referrals and refuse to provide timely call backs? If we are calling for orders or needing information, we are calling because we NEED it. I find that the hospital and SNF dc patients and do not feel obligated in any way to correct mistakes made on dc. We didn't give them prescriptions...sorry they are gone now! And MD offices...voice mail....no call back. We are just trying to help your patients!

Office/Clinical

I have heard that some offices handle this differently, so I am curious. Our nurses our in the field all day. They have to come into the office at the end of the day to fax labs, call MDs with results, get orders off their phones...I am curious if every office handles the orders and calls this way. If orders do get phoned to a nurse that works in the office it isn't called to the nurse in the field but just placed in her box. Many times Coumadin orders are phoned in office and orders are never written. That leaves the nurse calling the doc back and a very unhappy doc.

I guess this is just all so frustrating because I really care about my patients and the kind of care they receive. I know our companies have to make money, but I feel there has to be a focus on the care we are documenting this patient needs.

What do you think?

[Abbies]

cmarm, thanks for sharing. I have many of the same complaints. This is the 2nd HH agency I have worked with and although their approaches are different, they have similar problems.

1. Schedules - we get payed per hour, not per patient as at your agency yet with the same result that some nurses spend minimal time with pt. and max. time with "charting/office" hours. Or, these "speedier" nurses are often assigned heavier patient loads and receive pats on the back from Admin. for doing such an "efficient" job. Ever follow a nurse that made the patient/nurse-interventions look great on paper and when you follow you find a totally different picture because you actually take the time for proper assessment and teaching?

2. Qualifying patients - Yes to your post, I have seen the same. Do the words Medicare fraud ever cross your mind? Personally, I always chart what I see and let Admin. know if I find evidence that pt. is not home bound. I would advise you to keep a personal journal to CYB. Recertification??? Did we not just spend x amount of weeks seeing client that is now stabilized in her/his condition and technically not homebound, yet Admin. instructs you to re-certify and list same problems and goals as before, or they allow personal acquaintances to remain on services, taking advantage of the system because they have the power to? What do you say or do in these situations? I'm afraid to be a whistle blower and get fired. I really love my job, it pays well, provides good benefits and is relatively low on the stress meter.

3. Poor referral information/coordination - This seems to be an inherent systems problem. Everyone is so overwhelmed and the cracks have turned to crevasses. I keep names and phone numbers handy of those contacts that get me the results I need. I am always courteous, pleasant and grateful to the people I am extracting this information from. I try not to show my frustrations but to focus on building a professional friendship with them. It doesn't solve the big problem but does make it easier to deal with. Some HH agencies will not agree to take patients until all information has been faxed to them, i.e. orders, med lists, therapy notes, chart notes for the last 24 hrs, etc. Our agency, on the other hand, says yes to all and worries about the rest later. (They compete with other smaller agencies.}

4. Office/clinical - Alas, the poor office staff, the hub center, the glue that holds it all together. Our person wears many hats, stuck at the desk all day answering the phone that never stops ringing, doing the bills, processing faxes coming in, copying and faxing the insurance companies the endless amounts of documentation they hound her about before they will consider reimbursing us, filing, maintaining the records, tracking the computer updates and troubleshooting computers and the copy machine, doing the payroll, coordinating schedules, taking referrals, ordering supplies. Oh, and did I mention: bath aide duties when one calls off sick? The "go to" person everyone filters their problems through. Our person does not even get to go out for lunch and if she does she has the phones transferred over to her cell phone so she can continue to take calls while she is out. Usually she just eats at her desk while working and tries not to spill or dribble on the records or her keyboard. She always arrives an hour early for work so she can keep up (time that she does not claim). When she indicates to me that I'm on my own, I remind myself that I do not do her job for low wages. I do call her often and she will check for orders, etc. without being rude. I think she needs a raise.

[cmarn]

Very helpful information! You are right about the office staff. Although it can be frustrating, I do try to remember that I wouldn't trade places for anything. We are fortunate to have 5 clinical supervisors and at least 8-10 office staff, so luckily they aren't in the postion to bear the full burden alone.

The suggestion of keeping a journal was great. I have often considered documenting on the Oasis, "spoke with Jane Doe, RN who was aware of pt functional status (or whatever) and requested that pt be admitted for HH services" But the point isn't to get someone else in trouble...it is to CMA. With a journal of the calls I make and such at least I could refer to it in case a chart is questioned by MCR.

HH truly is a great job. It is holistic nursing at its best. If we can be welcomed into a patients home, we can learn so much about them and what their needs are. How many people have all of us seen who were discharged from the hospital with no competent person at home to help....no heat...no food...no transportation, etc. We see it and pull all of our resources together for good pt. outcomes. Gotta love it!