Missed visits

hoolahan, ASN, RN · Jun 20, 2002

Don't you control when to d/c the pt's? Are they Medicare? If medicare and they aren't home, that would be fraud to keep them open, and I won't do that, and put myself in the path of fraud charges for anybody, pt, doc, or agency.

If not medicare, and don't have to be homebound, then I document all attempts to visit in the progrss notes. ON what I decide will be my final attempt, I usually go by the 3 strikes and you're out policy, b/c we don't have a policy, (policy? who needs policies, why not every nurse do it differently? Consistency? Who needs that??) ON the last try, I slip a progress note under the door, it will say something to this effect...

"Dear_________

You have not been home for a nursing visit at the agreed upon time for 3 out of the last 3 attempts. When you agree to an appointment, and are not home, this takes away a visit from another client who is home, and needs nursing care. I need to hear from you by __________ (I usually give them 2 -3 days.) If I do not hear from you by that time, you will be discharged from the agency.

Sincerely,

Ima Nurse

Phone:xxx-xxx-xxxx

Supervisor Shesa Nurse Phone xxx-xxx-xxxx"

Then, on the said date, I chaeck my voice mail at the end of the day, if I or my supervisor has not heard from them by then, I d/c them. Now, if it is someone who is frail, I will call the emergency contact person and inquire as to the status of the person, maybe they are in the hospital, or away at a funeral out of town, or have a good reason for missing appt's. If so, that is a whole other kettle of fish.

I had a young MS pt, newly diagnosed w severe renal HTN, and severe HTN 200/120, needed avonex inj, and to be instructed on glucometer for steroid-induced DM. I got 2 visits in out of 9 attempts. I did go the extra mile for him, b/c I believed his sob story...until his cousin blew his stack and flat out said, he is the most irresponsible person and he is sick of having to account for him, don't call again! OK---> D/C.

I write the note on the paper that makes copies, so I have a copy for the chart. When I get back to the office, I xerox it, and fax the note, and a cover letter to the doc, so he will know status.

They tried to re-refer Mr. Irresponsible, but we couldn't find him again on the first visit, and that was that for him, repeat offenders get one strike, if not still in the hospital. We have precious little staff to see so many, we can utilize out resources in a much better way than to waste time and milegae on people who aren't concerned enough about their own health to be present for a visit. IF the agency doesn't reimburse for time, I would flat out refuse to waste time going to these no-shows.

A lot of the problem, I truly believe is when the case is opened, pt's aren't truly assessed for exactly what their needs will be. If they can get out to social events, they can take themselves to the doctor's office as far as I am concerned. Also, people need to start really asking pt's on Medicare, would you describe yourself as homebound? For example, do you do your own shopping? Do you drive? Do you go to the senior center? Luncheon w friends?

Had a sweet lady today, went out and couldn't believe she was my pt, looked too young for medicare! She had cellulitits of BLE, and needed wound care. She had just gotten out of the shower, and said, I was going to do the drssing myself, but I'll let you since you're here. I asked if she could reach, and she did so w ease. I did one leg, she did the other w a tad bit of help w the kling from her hubby. OK, she shops, goes out, and said "My dr wants me to go for some outpt PT" OK, let me explain what medicare requires in order for you to recieve home care. She was actually glad, b/c she didn't want to be inconvenienced by waiting around for a nurse to visit, not exactly her words, but she meant it, in a nice way, essentially. So, I made it a SN eval visit only. Called the doc and said she's not homebound, I can't keep her case open, please send her a rx for supplies.

If the person openeing the case explained that they are expected to be home for visits, and if your agency put a statement to that effect in their brochure, maybe it would help. We have all just decided w alll the paperwork we have to do, we are not wasting one precious moment on people who don't need us. At least I won't. Another way to catch your medicaid non-homebound pt at home is to visit when their PCA is scheduled, they rarely miss their PCA's visit. I have 100% success by doing that.

TopazStone · Jun 20, 2002

We are mainly Medicaid. We manage meds and long term physical problems because the patients are constantly hospitalized if we don't assist (ie, check BS, apply skin treatments) and we do some social work as well. No, we don't decide when to D/C. I just had a patient probated for missing visits-- her mental stat has declined, she c/o back pain and vomiting (dx with acute renal failure and neurogenic bladder). Her BUN and creat are both elevated. She could very well die if she continues to refuse visits. Because this is the psych population, we bend quite a bit. It gets to the point at times where I could scream. The really sick ones-- I will do what it takes, but the ones that play games tork me off.

hoolahan, ASN, RN · Jun 20, 2002

Ah, that does put a whole different spin on things, but even more reason that your agency should have a policy, or maybe an ethics meeting, and certainly, this should be taken into consideration when it comes to meeting your quota.

But, even psych patient's need limit setting..."Mr. Jones, your time is up" Right? HOw about getting their guardian involved, or referring them to a community agency? We have one in my area for psych pt's where they can go each day to get meds, or they can get daily meds bubble-packed, if they are higher functioning. These folks who can get out easily do NOT need a nurse to come to them!!

adaptation · Oct 8, 2003

My caseload is purely psych.

The first time a patient is "not found" (not at home)- we are paid for that visit. (But only if we set up an appt. in advance).

After that, we are on our own. No pay.

A pattern of not found visits is looked at an individual basis before the pt. is discharged.

Did I mention that we are truly expected to try and FIND a not found patient? Bang on the door, try to find an open window, call next of kin...they're worried pt. might be dead on the floor.

I've had a pt. drive up while all this is going on. "Oh, did we have an appt. today? Sorry, I forgot."

renerian, BSN, RN · Oct 8, 2003

I have used contracts on psych clients and that spelled it out up front the need to be home and the d/c process.

renerian

rnhomeind · Nov 6, 2003

In our homecare, we clearly instruct medicare guidelines for homebound status. If they have private insurance, we usually know upon admit, if they are required to be homebound or not. Medicaid differs a little bit in our state, they are considered homebound, if they require an assistive device to leave the home. If it is medicare, I clearly state to the clients upon admit and reinforce afterwards, that they have to experience a taxing effort, but are allowed to leave for short infrequent periods that are not medical related. If I find out an elderly client went out for lunch, I dont immediately assume she is not homebound. I assess how she felt during and after. If she denies it being taxing, she may have just had a good day, so i make note to monitor homebound status. Everyone is different and there are multiple times, clients falsely say they are homebound to get our services, but I find, that eventually, the nurse will find out they are not homebound. If they request certain visit times, and I happen to attempt to call them for a new order and they are not home, but informed me yesterday, they would be home all day, without knowing I would be calling. Our agency is very consistent with monitoring this due to fraudulent billing under medicare guidelines.

HAVE A NICE DAY! :)