POLL: Calling the referring physician with report. Yes or no.

[iSurvivor]

For a SOC/ROC/RCT, should the nurse call the referring physician with report (assuming there are no acute changes in the patient's condition). Why or why not?

[NRSKarenRN, BSN, RN]

Under current Medicare Home Health Conditions of Participation, staff are required to consult physician as the PHYSICIAN is responsible for establishing and review plan of care. Calling is best as you need to date/time notification and should include who you spoke with at doctors office if physician not spoken to directly. Sending a fax does not guarantee it's receipt nor allow discussion.

§ 484.18

Condition of participation: Acceptance of patients, plan of care, and medical supervision.

Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing, and social needs can be met adequately by the agency in the patient's place of residence. Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine.

(a) Standard: Plan of care. The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items. If a physician refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration. The therapist and other agency personnel participate in developing the plan of care.

(b) Standard: Periodic review of plan of care. The total plan of care is reviewed by the attending physician and HHA personnel as often as the severity of the patient's condition requires, but at least once every 60 days or more frequently when there is a beneficiary elected transfer; a significant change in condition resulting in a change in the case-mix assignment; or a discharge and return to the same HHA during the 60-day episode. Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care.

© Standard: Conformance with physician orders. Drugs and treatments are administered by agency staff only as ordered by the physician with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per agency policy developed in consultation with a physician, and after an assessment for contraindications. Verbal orders are put in writing and signed and dated with the date of receipt by the registered nurse or qualified therapist (as defined in § 484.4 of this chapter) responsible for furnishing or supervising the ordered services. Verbal orders are only accepted by personnel authorized to do so by applicable State and Federal laws and regulations as well as by the HHA's internal policies.

Medicare's Proposed changes to Home Health Conditions of participation has more info, including requirements for patient to participate in care planning and receive a copy of care plan::

§ 484.60 Condition of participation: Care planning, coordination of services, and quality of care.

(a) Standard: Plan of care.

(1) Each patient must receive the home health

services that are written in an

individualized plan of care that

identifies patient-specific measurable

outcomes and goals, and which is

established, periodically reviewed, and

signed by a doctor of medicine,

osteopathy, or podiatry acting within

the scope of his or her state license,

certification, or registration. If a

physician refers a patient under a plan

of care that cannot be completed until

after an evaluation visit, the physician

is consulted to approve additions or

modifications to the original plan.

We would maintain the

intent of the current requirement at

§ 484.18© by proposing a

§ 484.60(b)(5) that a registered nurse

(RN) or other qualified practitioner who

is licensed to practice by the state must

document the order in writing in the

patient's clinical record, with a

signature, time, and date. As described

in the definitions section, for purposes

of this rule, verbal orders are those

physician orders that are spoken to

qualified medical personnel. Verbal

orders would also have to be recorded

in the patient's plan of care. Reliance on

a HHA to maintain physician orders in

written form would protect patients by

ensuring that the plan of care

incorporated all services and treatments

ordered by the physician who is

responsible for the home health plan of

care. If a physician faxed orders or

otherwise transmitted them through

other electronic methods from his or her

office, those orders would be required to

be included in the patient's clinical

record and plan of care.

[NRSKarenRN, BSN, RN]

If there is no written facility discharge plan with home care orders including visit frequency, then discussion with physician/office staff needed to meet standard of establishing plan of treatment on first visit.

National Association for Home Care and Hospice phrases it best:

Start of episode verbal orders, which are required prior to initiation of care to a patient, necessitate telephone contact with a physician to communicate discipline specific information (e.g. nursing, PT, OT, SLP) based on patient assessments. Since 50% of all home health episodes include at least one therapy visit, a minimum of two agency contacts and sets of verbal orders are required in half of all start of care episodes. During these contacts, which usually take place by phone after an evaluation visit by the home health clinician, information is relayed to the physician about the patient's status and a plan of care is developed for that discipline.

http://c.ymcdn.com/sites/www.aahcm.org/resource/resmgr/public_policy/physician_certification_rece.pdf

Surveyors use this document to guide them in evaluating if agency meeting Medicare Conditions of Participation

State Operations Manual Appendix B - Guidance to Surveyors: Home Health Agencies

[JustMeRN]

No, we do not routinely call the physician unless their are concerns or discrepancies. Nursing writes the orders (including frequency of visits) and the orders are sent (almost always electronically) to the physician for signature. You will very occasionally have a physician who does not agree with the plan of care, but usually they do. If they do not agree and we have already seen the patient the agency eats the cost of the visits (we are a non profit and non billable visits happen occasionally).

The problem with calling the physician (IMO) is that the referring physician is almost never the pcp who will be following the patient. We get the bulk of our patients from the hospital, and all of our local hospitals use hospitalist programs. So the referring physician is usually not even available the next day. They send us orders that are pretty vague, usually assess for sn needs, and we are expected to be able to evaluate the needed frequency and skilled need. Wound care orders are usually specific, but sometimes left up to the discretion of the nurses.

Imo calling for every admit is a waste of everyone's time, and creates more confusion. Using electronic means we have signed orders and plan of care quickly, and since there is no phone call there is no issue with verbal orders and miscommunication, everything is spelled out in black and white. When there is an issue and you need to call an office for a patient concern it's like a long drawn out game of telephone. Talk to secretary who tells you she will relay your message to the nurse who may or may not call you back before next Tuesday, who then might need to run your concern by the doctor, who may or may not tell the nurse to tell you to do xyz etc etc etc. I am a strong supporter of email communication for non urgent issues.

[Farawyn]

I call and tell them I've opened a case, and if there is med reconciliation or whatever I try to take care of it then. If there isn't, I still make the call.