Start of care orders

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Wondering how other agencies handle the requirement of getting authorization for orders prior to implementing the order specifically at start of care? From talking to a lot of nurses and therapist I have come to found out that they do not call the physician after assessing the patient unless there is something really unusual. And we know that referral orders almost never address any orders like frequency/duration....But that means that they start revisiting patients long before 485s/POCs come back signed and I have read several places that Medicare sometimes deny these visits; the visits after the eval until the date MD signs the POC, because there is no evidence of verbal authorization. So I am wondering if clinicians just sign there orders as verbal so that it looks like the MD was contacted or do they ask the MD to back date it because I can't think of any other way of handling this except to actually just pick up the phone and call. Please help. Thanks

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I recently started a couple of cases with my agency at start of care. The agency has very poorly constructed initial 485s with mostly useless boiler plate orders. I wrote up extensive clarification orders and sent them forward for signature. I would have called and got the TO except I work night shift, so not practical for me. Almost all of what I put down was routine. For example, everybody with a trach requires trach care, suctioning, etc. Better to be waiting on responses to these than to not have anything to cover what the nurses are doing in the home the way I see it. This agency, for some reason, does not have a nursing supervisor who is thorough with the initial 485. I refuse to work with no effort at obtaining appropriate orders so I can justify my care. I know that probably 9 out of 10 field nurses don't bother doing what I take the initiative to do.

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I actually put the date I send the order sheet forward. I don't back date anything unless it is appropriate. The doctor can date the form as s/he sees fit and they can modify or delete anything they don't agree with. At least I've tried to get a piece of paper in the home to cover the nurses on the case.

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Specializes in LTC/hospital, home health (VNA).

The date of referral is also the verbal start of care date. If the office personnel/referral taker has any doubts - they clear it up. The official orders are on the 485, but the verbal SOC date allows us to be in there - it orders us to be there. Our software system/OASIS-C has that as "M" questions. So while I call to clarify anything after seeing the pt, if it is routine "stuff" that was why we were referred to in the first place - I know that the verbal SOC is sufficient. Hope that helps?? As a side note, in my experience - the docs KNOW that we are good at what we do ...and the referral is so we can go in and assess, perform, teach...and then report back to them with the outcome...they know we are independent clinicians that are their eyes/ears in the home and they respect that. They know that is what we are going to do when they give us a referral...no need to call them to tell them we are going to do what they have already asked us to do..hope that makes sense.

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Pick up the phone and call. Obtain V.O. - At our agency we do not treat the entire 485 as a V.O. - We document on our SOC OASIS that V.O. was obtained. Period. Has not been a problem thus far.

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Pick up the phone and call. Obtain V.O. - At our agency we do not treat the entire 485 as a V.O. - We document on our SOC OASIS that V.O. was obtained. Period. Has not been a problem thus far.

help me out here, when you call the md office do you leave a voice mail? if so do they call you back?? if not do you have to keep calling??? or is the message you left sufficient??

they are telling us now that we can leave a message but it is not a VO until someone calls us back, easier said than done....they are saying we can't go back to see that patient until we get that call back,,,most offices are equiped with voice mail, very few receptionist will take this message......what to do. i am still waiting for the md office to call me back after today's soc, i called at 1 and by 7 no call back, so now tomorrow i have to call again,,,,and i had wanted to see this patient tomorrow (new MI, all new meds).....we are all going crazy!!!

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My supervisor on one case told me that she went out of her way to develop a working relationship with the MD's nurse. If possible, you should attempt to do something like this. It could go a long way to smooth the process of phone calls and call backs and timely orders.

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help me out here, when you call the md office do you leave a voice mail? if so do they call you back?? if not do you have to keep calling??? or is the message you left sufficient??

they are telling us now that we can leave a message but it is not a VO until someone calls us back, easier said than done....they are saying we can't go back to see that patient until we get that call back,,,most offices are equiped with voice mail, very few receptionist will take this message......what to do. i am still waiting for the md office to call me back after today's soc, i called at 1 and by 7 no call back, so now tomorrow i have to call again,,,,and i had wanted to see this patient tomorrow (new MI, all new meds).....we are all going crazy!!!

That's exactly my problem too. We all know in most of the cases physicians do not care about the exact frequency/duration and stuff like that, so it's not like we can have them paged or the covering physicians paged to get these non emergency orders. Yet we can't revisit without showing an evidence of verbal authorization. The first order that the agency gets is usually "eval and treat"and that order is only good for the first eval visit not the revisits. This is especiallly a big problem with therapy evals. They eval and start seeing patients even before turning in the evals and never ever call the physician to get a verbal authorization for the plan.

However, there is box on the physician's order form that a clinician can check off if whether an order is a written order or verbal order. I see lot of nurses checking off the verbal order box but I doubt that they actually contact the physician. But then I haven't seen any PT orders with that option so I don't know how they get away with this requirement? I guess I am trying to figure out a way I can get out of contacting a physician, and still be compliant and not run the risk of Medicare denying these visits (of course there is no exception if it's something important like med verifications, invasive testings/treatments including Blood sugars and so on.. )

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That's exactly my problem too. We all know in most of the cases physicians do not care about the exact frequency/duration and stuff like that, so it's not like we can have them paged or the covering physicians paged to get these non emergency orders. Yet we can't revisit without showing an evidence of verbal authorization. The first order that the agency gets is usually "eval and treat"and that order is only good for the first eval visit not the revisits. This is especiallly a big problem with therapy evals. They eval and start seeing patients even before turning in the evals and never ever call the physician to get a verbal authorization for the plan.

However, there is box on the physician's order form that a clinician can check off if whether an order is a written order or verbal order. I see lot of nurses checking off the verbal order box but I doubt that they actually contact the physician. But then I haven't seen any PT orders with that option so I don't know how they get away with this requirement? I guess I am trying to figure out a way I can get out of contacting a physician, and still be compliant and not run the risk of Medicare denying these visits (of course there is no exception if it's something important like med verifications, invasive testings/treatments including Blood sugars and so on.. )

this is what i am trying to figure out too, i don't mind at all callling after a soc etc and leaving a message that i have opened up the patient for sn , pt ot and msw, etc....but having to get verbal confirmation is total ridulous! i am smart enough to know when i need to speak to a person,,,,how many doc's offices are going to get ****** when they are getting calls like you want go put a duoderm or a small stage 2, we can't technically put it on with out the "OK" , so we wait and now we have a stage 3 or worse!!!!! patient care will suffer,,,,i will take care of the patient first and i think any reasonable nurse will also.

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With the implementation of OASIS-C, there are actually a couple of issues here.

In terms of compliance, it is required that services are provided under the direction of a physician (or podiatrist). The referral gives us the ok to do the eval. We should then be calling the MD office to report our findings and obtain a V.O. to provide further services. The reality is that most nurses just call and leave a message, or if they're lucky, talk to the office nurse, and say "I admitted Mrs. Jones with freq blah blah for A/O of blah blah". Short and sweet, certainly not a summary of the entire 485. At my current agency, the nurse documents "V.O. obtained" on her SOC OASIS and we call it good. An agency I have worked for in the past did not even do this much, and neither has had any problems with it on survey. You are then good to go for return visits.

However, if you are looking at the new OASIS-C Plan of Care Synopsis item (M2250), the item-by-item guidance says that in order to respond "Yes" to any of the subcategories, " 'The physician-ordered plan of care' means that the patient condition has been discussed and there is agreement as to the plan of care between the home health agency staff and the physician... This question can be answered 'yes' prior to the receipt of signed orders if the clinical record reflects evidence of communication with the physician to include specified best practice interventions in the plan of care..."

So... clear as mud?

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With the implementation of OASIS-C, there are actually a couple of issues here.

In terms of compliance, it is required that services are provided under the direction of a physician (or podiatrist). The referral gives us the ok to do the eval. We should then be calling the MD office to report our findings and obtain a V.O. to provide further services. The reality is that most nurses just call and leave a message, or if they're lucky, talk to the office nurse, and say "I admitted Mrs. Jones with freq blah blah for A/O of blah blah". Short and sweet, certainly not a summary of the entire 485. At my current agency, the nurse documents "V.O. obtained" on her SOC OASIS and we call it good. An agency I have worked for in the past did not even do this much, and neither has had any problems with it on survey. You are then good to go for return visits.

However, if you are looking at the new OASIS-C Plan of Care Synopsis item (M2250), the item-by-item guidance says that in order to respond "Yes" to any of the subcategories, " 'The physician-ordered plan of care' means that the patient condition has been discussed and there is agreement as to the plan of care between the home health agency staff and the physician... This question can be answered 'yes' prior to the receipt of signed orders if the clinical record reflects evidence of communication with the physician to include specified best practice interventions in the plan of care..."

So... clear as mud?

ok, sooooo does it mean that we can still just call , leave a message like we always have, but if we are answering yes to any of the items in M2250 then we "truly" need to have that 2 way discussion???????

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Specializes in PICU, NICU, L&D, Public Health, Hospice.

I call and speak with the RN who works with the physician many times...given that this nurse knows the practice preferences of the MD she will often okay the verbal order for the poc I have outlined. I would then include her name in the verbal order. If she is not sure about a particular aspect I give her the number to the RN in our office, with fax info, so that the legalities and specifics of the order sets can be clarified. I WILL answer no, no, no to MOO questions about MD agreement if I cannot verify same. I know of an agency who has an RN in intake which obtains VO for basic SOC orders at time of referral, this allows the admission nurse to admit without hassle and makes the case nurse responsible for tweaking the plan during the course of the care episode. The SOC nurse then only needs to speak with the referring MD if there is something unexpected and important noted at admission that should be addressed immediately.

Good luck.

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