RNs opening cases, LPNs making all revisits?

[HealthyNurse]

Does anyone work for an agency in which RNs are responsible for performing the SOC (and any subsequent OASIS assessment) and then the LPNs make all the revisits? My agency is moving toward using this model and I would like some feedback on your experience with this.

[KateRN1]

Yes, I am currently a manager but have many years under my belt and still see patients as a field nurse. I have worked where the cases are managed by the office, I've done primary nursing, team nursing, and case management. It's not that any one particular way works better than the other, but that each is a different fit for the individual and the agency. When you are new to home care, nothing feels right because it is a completely different ballgame than anything you've ever done. Inherent in any of the care models, though, is that the right policies, procedures, and processes must be in place to support the style that is used and willingness of the staff to participate. If you know that you aren't comfortable delegating patient care to an LPN, then make sure you address that in job interviews and don't take positions that use that care model.

[AnnemRN]

I think it's important for the RN to see their patient's at least once each week. The LVN's where I work are so overloaded with patient's they are unable to address problems they encounter and many times they don't report them to the case managers. I am shocked at what I find when I follow some of these patient's - many of them have the beginnings of serious complications such as wound infections, respiratory infections that have been going on for several visits, but they are not reflected in their notes. One patient on coumadin was having bleeding from the rectum which the family reported to the nurse - the LVN told the family she would put that in her note. The patient ended up in the ER.

[HealthyNurse]

Our agency also utilizes this model and it can work well if applied appropriately. About half of our cases are opened by the RN and staffed by the LPN for revisits. The RN generally makes the decision about whether s/he will keep the patient or delegate to the LPN. What is required in using an RN Case Management model is great communication between the staff. I expect the RN and LPN to communicate at least weekly and more often if there are issues with non-compliance or non-adherence to the medical regimen. The RN retains the ultimate responsbility for the case and is responsible for 30-day summaries on all his/her patients, as well as the recert or discharge. It really isn't any different than LPNs who work on hospital floors, the RN still retains the responsibility for the patient care.

I would argue that it IS different from LPNs working on a hospital floor, because the RN can easily go into the room and visualize the patient on the hospital floor, if need be. In home care, there is much more autonomy. Does the patient's payor source impact the decision to delegate the care to the LPN in your agency? That is one of my issues with what my agency is doing- it is not based on clinical needs, but on the payor source, with managed care patients getting assigned to LPNs.

[HealthyNurse]

I think it's important for the RN to see their patient's at least once each week. The LVN's where I work are so overloaded with patient's they are unable to address problems they encounter and many times they don't report them to the case managers. I am shocked at what I find when I follow some of these patient's - many of them have the beginnings of serious complications such as wound infections, respiratory infections that have been going on for several visits, but they are not reflected in their notes. One patient on coumadin was having bleeding from the rectum which the family reported to the nurse - the LVN told the family she would put that in her note. The patient ended up in the ER.

This is also what we are seeing in my agency- lots of issues related to inappropriate follow-up, not reporting issues to the RN case manager, and very serious incidents resulting. It is frightening.

[caliotter3]

If the LPN does not see fit to pass along information, it may never surface. Many times I have noticed that the family does not place very much, or any, importance on that same information. When the LPN who sees the patient on a regular basis doesn't follow up, you can't expect the supervising RN to magically figure things out on a quick, routine visit. The family member will look right at her and say, "Everything is ok", when it may or may not be.

[AnnemRN]

I believe having the RN open cases only to have LVN's do all of the routine visits is a recipe for disaster. In my agency, the LVN's are loaded up with far too many patients to be able to provide optimal care. It is not only unfair to the RN & LVN, but also to the patients on service. Too many things are being missed - not only serious symptoms, but decisions regarding when to change wound care or having the time to order needed supplies just to name a few. All of these factors are having a major impact on patient outcomes.

I find it's important for the RN to be able visit the patient in order to carefully assess the patient and home situation. I don't think reading a narrative or getting report is enough.

[AnnemRN]

If the LPN does not see fit to pass along information, it may never surface. Many times I have noticed that the family does not place very much, or any, importance on that same information. When the LPN who sees the patient on a regular basis doesn't follow up, you can't expect the supervising RN to magically figure things out on a quick, routine visit. The family member will look right at her and say, "Everything is ok", when it may or may not be.

In regards to the family who told the LVN about the patient's rectal bleeding, they were very upset when I happened to see them a week later. They did place importance on the information conveyed, in fact they told me " We told the nurse because the nurses have been telling us to report any bleeding and when we did nothing was done."

They were not happy that they were not given any direction on what to do, so they took the patient to the ER. The patient's PT/INR were too high and coumadin needed to be held. The case manager knew nothing about it and it was not reflected in the LVN's note.

[caliotter3]

Family members who are interested in passing on information are in the minority in my experience. The ones who are interested, more often than not, want complete control, and will get angry when the nurse does any kind of reporting or follow up. I have been angrily jumped upon by family members for doing my job and have had to tell them that I will do my job or leave the case. I think this type of response may turn off a lot of nurses from getting more than "minimally" involved. Or, they just don't like the extra work involved with writing something in their notes, writing a communication note, calling the supervisor, and calling the doctor. They hope they can just leave things in the corner and they will go away with no work on their part.

[peacetou]

I appreciate your posting this very important issue. I would like to give you my input on the subject. As a LPN, I have been hired to do revisits. I have not worked in home health much but I have worked in many other areas of healthcare. I would like to go into this new job with a positive attitude and a happy heart. Although I have much respect for the RN, I have to say that reading the responses from other RN's makes me question my desire to return to nursing. I understand the economics of the situation but what is, is. I would appreciate more support from the team I work with. When the "team" mistrusts me and my capabilities before they even know me, I am already in hot water. How can I do my job when I am confronted with negativity and suspicion? Of course, I have to call to ask questions...that is part of my job...to seek advice from the RN's, case workers, managers or superiors, if you prefer. Yes, it would be nice if all LPN's knew all the answers to the many questions that come up. Yes, it would be better if RN's saw their patients at least once a week. But since this may not be the case, could you try to work with me to reach the goals and not be condescending? If so, I promise I will do my best to give quality care.

Thank you for allowing me to respond.~