New to home health... lots of specific questions.

[godiva]

I posted a while back about a new job I got, and it was recommended that I find a new agency. My frustration led me to do just that about a month ago. I started last week at a new place, but it is small and has only been around for a year. They do a mix of private pay, Medicaid, Medicare, and home infusion. The owner (also an RN) and DON seem wonderful, professional, honest, and willing to do what it takes to be a respectable company... but since they are new, there are a lot of loose ends at the moment. The DON is not very familiar with Medicare and the owner is just way too busy making visits at this point. I don't want to bother her with endless questions, so I thought I'd tap you wonderful people as a resource. :)

Before I start, let me just say I absolutely love home health. I'm never bored, and I love the independence and feeling like I have more influence than I do at the bedside. I feel less like a cog in the wheel and I get to know my patients. I hope that I am able to make a life-long career out of it.

Okay, so my questions!

1) Diabetic patient. Has a glucometer, doesn't take sugars regularly or at all. What do you document on the Oasis (or at least the computer program we are using)?

2) Mixed case. Someone describe this to me so I understand it.

3) Non-compliant diabetic Medicaid patient. Frequent hospitalizations... noncompliant with meds. Discharge, or continue to provide an aide? How do you document if you are keeping the patient?

4) What happens in Medicare if a bedbound patient develops a pressure ulcer and peri-area excoriation under your care? The one I'm thinking of refuses to be turned, changed as often as needed, etc... the ulcer was inevitable.

5) Patient getting Medicare wound care and an aide through Medicaid. Cancels the aide often. Not compliant enough with advice to allow the pressure ulcers to heal. What to do? Discharge? If we do, he will get no wound care and end up in really, really bad shape.

6) Good publications to subscribe to and/or read to keep up on industry practice, common company policies, reimbursement trends, etc...?

Except in really obvious cases where patients request outright fraud or enable it, I often feel like discharging is extreme.... I feel like I'm abandoning the patient. What we give them is more care than they would get without us, so I am conflicted. Not to mention, companies don't like it if you are discharging left and right and not making them money. LOL Non-compliance is so common and I am having a hard time finding the fine line between honest documentation that covers my butt and well... the alternative. Doesn't Medicare know that most patients aren't willing to do what it takes to get better? It seems every nurse handles this stuff differently, at least the few I've come to know in home health.

Thanks for the advice, folks...

[LadyT618, MSN, APRN, NP]

I have attempted to answer your questions below (immediately after each question)....key is to document your efforts to change the situation and document all thatyou have done. In the end if it's not getting you anywhere, sorry, you gotta discharge. That patient may cost you more if they stay on service than if you let them go.

1) Diabetic patient. Has a glucometer, doesn't take sugars regularly or at all. What do you document on the Oasis (or at least the computer program we are using)? There is specific OASIS M-item that addresses how often the patient checks blood sugars. This information you would document in the narrative portion of your documentation of the visit.

2) Mixed case. Someone describe this to me so I understand it.

3) Non-compliant diabetic Medicaid patient. Frequent hospitalizations... noncompliant with meds. Discharge, or continue to provide an aide? How do you document if you are keeping the patient? Remember in home health, it's all about medical necessity. Medicare and Medicaid, as well as insurance companies want to ensure they are getting their money's worth, so the documentation must reflect WHY you need to see the patient and it must be skilled. As far as Medicaid is concerned, I believe they can get benefits via the state Medicaid benefit should the patient qualify for a provider service. Home health cannot be utilized strictly for the need of an aide.

4) What happens in Medicare if a bedbound patient develops a pressure ulcer and peri-area excoriation under your care? The one I'm thinking of refuses to be turned, changed as often as needed, etc... the ulcer was inevitable. In home health, many agencies feel that once a patient is under their care, they're stuck for life. The patient has a responsibility to adhere to the rules of the road and the Plan of Care. If they are capable of moving and refuse to turn, then they are not adhering, then the agency is free to discharge (just be sure that these instances are documented and what you tried as an alternative must be documented as well and let the physician know of your plan to discharge the patient and give them their 2-day notice or 5-day inthe state of Texas). If it's a matter of the caregiver not turning the patient, then I would search for another caregiver, reach out to family if available and more than likely may have to get Adult Protective Services on the case since the caregiver is essentially neglecting the patient.

5) Patient getting Medicare wound care and an aide through Medicaid. Cancels the aide often. Not compliant enough with advice to allow the pressure ulcers to heal. What to do? Discharge? If we do, he will get no wound care and end up in really, really bad shape. Similar to situation above. Is this patient ambulatory? Is he homebound? Why is he cancelling the aide all the time? Remember, they must hold up their end of the bargain in order for home health to work. It's one thing to not be ABLE to do wound care, which is what Medicare looks for, but it's another for the patient not to be willing and Medicare could care less if you're able but not willing, they won't pay for the services when this is documented in the record. Is there a barrier to learning? Explore ALL options and document ALL efforts before preparing for discharge.

6) Good publications to subscribe to and/or read to keep up on industry practice, common company policies, reimbursement trends, etc...? The Home Healthcare Nurse Journal published by Lippincott is a good start. Google Lisa Selman-Holman and subscribe to her blog (she is a home health guru). This should get you started.