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I spoke to a director of a skilled home heathcare agency who said it can take months to get Medicare to pay for needed DME (homecare beds, commodes) for her patients. She said there are at least two problems with the new Medicare rules. First, the new Medicare rules require home care patients (who are often home-bound) to visit with a physician who must document their needs for DME, and write a Certificate of Medical Necessity. The agency must then go through the application process to obtain the equipment using the certificate. Clearly the difficulty of getting the patient to the doctor's office in the first place, and then getting the certificate and submitting the paperwork creates a roadblock. On the supplier side, she said the new Medicare bidding requirements for who is allowed to supply the DME have resulted in large nationwide companies putting in low bids which crowd out local DME suppliers. These bids are so low that the supplier companies cannot make money on a variety of DME items and therefore try to avoid actually renting some types of equipment to patients. They drag their feet and slow or halt the process, and the patient has to wait and in some cases is denied the equipment for a variety of reasons. Are these problems being experienced by other caregivers in homecare agencies?

Libby1987 - I have never heard of reimbursement for Hoyer lift training in the home for primary caregivers. I thought the DME delivery company that rented/sold the lift did what little training there was. If reimbursement were available, ideally a PT would do the training however I assume home health care nurses (LPN, CNAs) could also do it. In either case, I think the hospital release coordinator (or the case manager at the home health care agency) would be responsible for requiring that two trained caregivers (2 family members, or a nurse and a family member) were present when using any lift that they authorized for home care. If a patient got hurt without the two trained caregivers present, the hospital or agency could be held liable. I personally have had dealings with one of the larger internet sellers of lifts who supposedly have salespersons with an average of 10 years experience. The salesperson I talked with had no idea how many people were required to use the lift even though the literature at the site strongly recommended that two caregivers be present. It seems that people who buy lifts on the net will not get much information or support about how to use them. They will need to depend on medical professionals for that.

It seems that unless there is lots of family caregiver support, many patients would be forced into LTC.

Thanks to all for their comments. It seems like there is no standard for training in the use of lifts. However when it is done, PTs are the best sources of training. But not all people that leave a hospital or an in-patient rehab facility are assigned a home-based PT. It would be interesting to know if PTs and nurses routinely request Hoyer lift rental in the home if the patient cannot bear weight or cannot provide the caregiver much assistance in moving from the bed. But then they would also be responsible for doing the training themselves.

Thanks for your comment CoffeeRTC. What concerns me is the negative psychological effect on these patients who are treated like infants (whose dirty briefs must be changed) when they are normal older people who need toileting help in a limited time frame (10 -15 minutes). Imagine how depressing and demoralizing it is for these pts. The sad thing is that changing multiple patient's briefs may actually take longer and be less efficient than attending to their toileting needs one at a time. However following a set schedule often does not permit such "as needed" toileting requests. But even if it takes a little longer to keep patients out of briefs, the positive psychological effect on the patient, his or her family, less stress on the CNAs (who often dread changing multiple patient's briefs), and fewer problems with skin breakdown would seem to justify some additional staff.

I am asking this question because there seems to be so much concern in LTC settings about under-staffing of CNAs. Say you have a dependent pt (who requires help in transfer) in bed or in a wheelchair who can be toileted on a commode but can normally only hold it for 5-10 minutes. If the facility is under-staffed, that pt is likely to wet or soil him or herself before the CNA can attend to them. That pt will then likely be considered incontinent. If a patient requires a two-person assist transfer to a commode (or toilet) and only one caregiver is normally available, the same thing can happen. If a patient requires a one-person assist transfer but the caregiver is often not available, again the patient may be considered incontinent. These patients (who may not actually be incontinent by common standards for older patients) will likely be put in briefs and have to be changed in bed periodically. However this activity can be scheduled whereas giving them toileting assistance as needed cannot be as easily scheduled. So the incentive is to diagnose them as incontinent and the indignity of being in briefs and being changed may be more common than it needs to be. Changing briefs is a labor-intensive and difficult activity and being in briefs can contribute to skin breakdown. I am wondering how common this questionable incontinence diagnosis is in LTC settings.

Patient care plans usually designate how to transfer patients who need assistance sometimes describing them as one-person or two-person "transfer assist" patients. However a patient who is fresh, alert, and orientated most of the time often becomes disorientated and unable to follow directions or communicate effectively with the caregiver (often later in the day). Such a patient would clearly be designated as a candidate for using a patient lift to transfer them in these circumstances (regardless of what the care plan says). The SPH&M flowchart from VISN8 concludes that full body lifts should be used when a patient is not cooperative or cannot follow directions. (reference: http://www.visn8.va.gov/VISN8/PatientSafetyCenter/safePtHandling/SafePatientHandlingAssessment_Algorithms_121112.doc ) My question is: How do nurses handle transfer for these patients whose moods and skills vary so much based on time of day, level of consciousness, most recent medication, etc.? It seems like a new ad-hoc assessment must be done every time these patient must be transferred. This seems like a big patient safety issue that is difficult to address.

If you look at the settings page, it says highest education and it has different degree options (mostly nursing). It also has an "other" option. It then has "years of experience". I chose "other" (non-nursing) and gave my engineering degree. The experience is 15 years of "other". If the site interprets this as 15 years of "nursing experience" when I clearly state otherwise, it needs to be rewritten. But thanks for judging me. Makes me feel welcome at this site.

4 years as an aide. 15 years as a hospice volunteer. 20+ as an engineer. Hope this helps.

I have no connection with either company or product I mentioned. But I do think transfer chairs are the answer to some of the problems nurses confront, especially when mobilizing patients who cannot tolerate lifts. As a former aide and Hospice volunteer, I have watched patients struggle with being bedfast for weeks and months on end. It is a very serious situation and the nurses and caretakers I worked with found it difficult to watch also. I do not see it as "advertising" to recommend a generic type of medical device (transfer chair) that solves a difficult challenge for nurses.

I agree that prolonged bed rest is dangerous. Pressure ulcers, hypostatic pneumonia, blood clots, and UTIs can all result from staying in bed for days at a time. There are mobility devices that allow patients with fractures to be mobilized and moved into sitting (or partially inclined) positions but they are not that common in hospitals and nursing homes. Being in a sitting position reduces most of the above medical complications (especially pressure ulcers). Two of the better known devices (usually called stretcher or mechanical chairs) which allow for "supine transfer" are the Barton Chair (model H250) and Wy'East TotaLlift II Chair. You can see how they work in the Youtubes listed below. However most LTC, hospital, and rehab facilities will not spend the money to buy these devices in spite of their being useful for patients such as the one you mention above. But it is good to be aware that they exist should the facility come up with some money and ask nurses what equipment they might want to buy to make their jobs easier by patient transfer and improve patient outcomes. Barton transfer chair: Wy'East Chair:

Common things that can happen with a hoisted patient (using a ceiling lift or floor lift): 1) Panic attacks (due to being disoriented during hoisting) - often happens with dementia or confused patients 2) Sundowning - erratic or violent behavior, screaming, flailing around in the sling while hoisted 3) Increased pain due to being bent and compressed by the sling (acting out is more likely due to pain) All of these situations require that a second caregiver be present to steady and calm the patient (to prevent injury) since the first caregiver must control the position of the sling with the buttons (with at least one hand). A lift company that recommends only one caregiver be present seems to be taking an unnecessary risk. You are right to worry about using a ceiling lift if you are the only caregiver present.

Hoyer lifts are sometimes used in home care nursing but lack of space, heavy pile rugs, difficult storage, and untrained or too few caregivers are often challenges to home use. So many total care patients may remain bed-bound even if a hoyer lift is available. Since most patient lift manufacturers strongly recommend two trained caregivers be present during transfer, a home care CNA and a family caregiver together can sometimes do the hoyer transfer working together. However the family caregiver should be trained in the use of the lift to prevent patient falls or injury. The questions are: 1. How much training is required? 2. Who does the training? 3. Where is it done? 4. How can it be determined if the home caregiver is strong enough to be of assistance and adequately trained in the use of the hoyer lift?

Many times a pt is put on the commode with the assistance of two nurses/CNAs or using a hoyer lift with a toileting sling (with two nurses present during the transfer). Then the second nurse goes about his or her duties leaving the first nurse to do peri-care/hygiene when the pt is finished. The patient often cannot stand up with the assistance of a single nurse especially if the nurse has to clean them up at the same time. If using a hoyer lift, it is against the rules to hoist a patient with only one nurse present. So the patient's peri-care cannot be done by a single nurse with the patient hoisted. So my question is: can the patient lean to one side while on the commode to receive adequate peri-care or is this impossible? Is the only solution to get the second nurse back in the room to help before doing peri-care?

There is a some evidence that says that doctors prefer to die at home in Hospice because they are much more informed about what is coming however: "Research shows that most Americans do not die well, which is to say they do not die the way they say they want to — at home, surrounded by the people who love them. According to data from Medicare, only a third of patients die this way. More than 50 percent spend their final days in hospitals, often in intensive care units, tethered to machines and feeding tubes, or in nursing homes." But doctors have more control, are better informed, and can make better decisions concerning their death and how they want things to progress: "When it comes to dying, doctors, of course, are ultimately no different from the rest of us. And their emotional and physical struggles are surely every bit as wrenching. But they have a clear advantage over many of us. They have seen death up close. They understand their choices, and they have access to the best that medicine has to offer." Source: The New Your Time article: http://www.nytimes.com/2013/11/20/your-money/how-doctors-die.html?_r=0