Md referral/pt education

[ap05]

Something that confuses me a bit....when we get an md referral for nursing care and therapy why do we have the responsibility of saying there is no nursing need? I have run into a couple circumstances where the pt was referred for nursing, I scheduled a few visits for education/monitoring and QA has informed me there is no need for nursing. Apparently the md who referred this pt disagrees. How do I have the authority to go against md orders and decide there is no need? Even if it's a small need? This is really starting to bother me as I feel I'm given responsibility yet no autonomy. If I feel a patient would benefit from a few visits, and they have been referred for the same reasons, isnt this reasonable? My manager told me goals need to be measurable, which I get, but how is education ever really measurable without a test? I would appreciate some insight.

[syoung078, BSN]

Sometimes it's a billing issue. For Medicare and other insurance you need to prove that there is a skilled need and that they are homebound typically. Otherwise your agency will be paying out of pocket and visits aren't covered/reimbursed. You need to really document in your assessment what the skilled need is that requires a skilled nurse. Otherwise, I would refer to other community programs for education. If the physician can help that's a plus but it's all in the wording and documenting your teaching and pt's response to teaching. So if there's a med change you can explain med teaching/mgmt needed and explain exactly what you review w/ the patient and their understanding or need for further teaching/reinforcement. Same if new diagnosis and need diet teaching etc. Lots of MD's also refer to home health without knowing what we can and can't do as an agency. Not all home health agencies are the same either and there are ones that are just for say medication pre-fill. I would talk with your manager as well to see what other resources are available in the community and discuss with you what qualifies as a skilled need etc. That way if your agency can not see a patient or doesn't have a skilled need you can have MD refer to another agency instead so the patient gets what they need. I recently had to do this w/ a patient that wasn't homebound and we were going in just for med prefill and INR check which isn't covered as a skilled need by Medicare so we referred to another agency that could do this.