1wk9

Isabelle49 · Sep 17, 2011

1W9, hmm. I truly think if a patient needs home health, they should be seen at this frequency as a minimum. I have had patients and families who are totally resistant to discharge and those I will do an episode of QOW to get them ready for discharge.

2W9 - not unless the patient needs wound care or other care that they or the family cannot perform. The agency I work for would absolutely prohibit this. It would cut into their profits! I do have one patient that is 3X wk for wound care and the agency has no argument for this since there is no one to do the care and the patient cannot see the wound due to very low vision and location of the wound, not to mention she cannot stand up easily.

I had a patient not too long ago that had a BP of 190's/120's when OT saw them in the morning and did not report it. I saw her at approx 1pm and BP was very similar and this patient had home health for an accident with SDH among other things. Called her doc, had some of her meds resumed that were on hold, specifically BP meds and told her I would be back later in the evening to check on her. She took meds while I was there. Called my supervisor to let her know that I was going to see her again at about 7pm due to bp and meds resumed with recent hx of SDH. Supervisor said, 'they don't like us to do that'. I asked who 'they' was and she said corporate. I told her that was negligent and that I would be seeing the patient again. I saw her, wrote up a case conference of my visit and let the company know that I did this visit without charge to them as I didn't want to cut into their profits! What a waste!

twokidsmom,rn · Sep 18, 2011

It seems that the 1wk9 is usually for recerts. Most freq are 2wk2,1wk7. I am just use to seeing my pts twice a week then cutting to once a week for last 2 weeks before discharge. But this new company has many more nurses doing visits. Last company I did everything visits, CM, labs. Not use to having others see them.

KateRN1 · Sep 20, 2011

Wow, that's some high utilization. We rarely see patients that often and definitely not for "monitoring." Medicare home health is for the subacute phase of an exacerbation or new onset of illness. Frequencies like that are going by the wayside as fraud strike forces crack down on keeping patients for monitoring and unskilled care. Our goal should be to educate the patient/caregiver to foster independence. If independence isn't possible, referral to other non-Medicare agencies as needed. Get your MSW involved. If the patient hasn't had an exacerbation in more than 3-4 weeks and all you're doing is monitoring, the patient has met goals and needs to be discharged.

And never EVER do visits without "charging" the company. If a second visit in the day is required to follow up for something like B/P out of range, first get an order from the doc for a PRN visit for later the same day, turn in a visit note and whatever documentation you may need to get paid for the visit. By doing "free" visits, you are violating Stark Law in giving the patient something of value for no charge.

twokidsmom,rn · Sep 20, 2011

KateRN what is your average freq? With this new agency MANY pts are 1wk visits.

KateRN1 · Sep 20, 2011

We really don't have an "average" frequency. Ramping down using every other week visits is common, as is 1M2 for therapy-only cases (our RNs do all OASIS and case management). Patients who have a high risk for (re)hospitalization will be seen more frequently and patients who need dressing changes and no caregivers are seen more frequently when needed.

For an example, a patient who comes as an MD office referral for med management and diabetic education without any other needs might be seen 1W3, QOW6 + 3 prn visits. But a patient discharged from the hospital following an initial CHF diagnosis might be seen 3W1, 2W1, 1W1, QOW6 + 3 prn. IV patients are generally seen at least once a week for PICC line dressing changes (or portacath dressing).

The goals are to front load patient education to prevent hospitalization, teach the most important things first, then work on getting them as independent as possible. Patients who are never going to be independent are referred as quickly as possible to MSW to get other services in place to prevent needless recerts.

momsnurse1 · Sep 22, 2011

Kate,

"Medicare home health is for the subacute phase of an exacerbation or new onset of illness." This has always been my understanding of the purpose of home care but I am now being told that it is the "old school" way of thinking. We are now being told that home care is to prevent rehospitilization and it is OK to keep people on service to prevent further decline and to continue to recert them. I do not agree with this new philosophy as I think that it prevents patients from gaining the independence that they need when they think we are going to be around forever. Not sure how to get others to realize what the real philosophy of home care is, or am I really just "old school"and need to modernize my way of thinking.

KateRN1 · Sep 22, 2011

No, you are right on the money in my opinion. The purpose of Medicare home care has not changed at all from its inception. I would ask for some literature that supports the need to change your "old school" way of thinking. Or wait for a survey to hit and then do the "I told you so" dance. LOL

Isabelle49 · Sep 22, 2011

Wow, that's some high utilization. We rarely see patients that often and definitely not for "monitoring." Medicare home health is for the subacute phase of an exacerbation or new onset of illness. Frequencies like that are going by the wayside as fraud strike forces crack down on keeping patients for monitoring and unskilled care. Our goal should be to educate the patient/caregiver to foster independence. If independence isn't possible, referral to other non-Medicare agencies as needed. Get your MSW involved. If the patient hasn't had an exacerbation in more than 3-4 weeks and all you're doing is monitoring, the patient has met goals and needs to be discharged.
And never EVER do visits without "charging" the company. If a second visit in the day is required to follow up for something like B/P out of range, first get an order from the doc for a PRN visit for later the same day, turn in a visit note and whatever documentation you may need to get paid for the visit. By doing "free" visits, you are violating Stark Law in giving the patient something of value for no charge.

My BON allows nurses to volunteer their services.

KateRN1 · Sep 23, 2011

What your BON allows and what is allowable and legal under Stark law are two entirely different things. Providing nursing visits without charge while the patient is under care with your agency is a serious boundary violation for you as a professional at the very least and can be considered violation of Stark law which is punishable for both you as a professional and your agency as a whole for fraud.

If the patient is not under service with your agency, then you can provide whatever you like, but I'd still caution you to be very careful and always carry your own Liability Insurance.

I also provide volunteer services, but not to the patients who are serviced by my agency or any patients that have been discharged by my agency. Completely separate issue.

Isabelle49 · Sep 23, 2011

What your BON allows and what is allowable and legal under Stark law are two entirely different things. Providing nursing visits without charge while the patient is under care with your agency is a serious boundary violation for you as a professional at the very least and can be considered violation of Stark law which is punishable for both you as a professional and your agency as a whole for fraud.
If the patient is not under service with your agency, then you can provide whatever you like, but I'd still caution you to be very careful and always carry your own liability insurance.
I also provide volunteer services, but not to the patients who are serviced by my agency or any patients that have been discharged by my agency. Completely separate issue.

How would the Stark Law apply to me? I thought it governed physician self referrals and kickbacks??

KateRN1 · Sep 26, 2011

That is the majority of it. However, it also covers things like marketing materials and providing gifts and free services to patients. Agencies are limited to $10/gift up to 5x/year for a total of $50 per patient. If the nurse is providing free services to patients that the agency ordinarily does not provide, there is room to say that the agency is providing an enticement to keep the patient--providing a kickback to the patient--to keep him/her on service vs. going to another agency. Nursing visits are certainly worth more than $50. That may not necessarily be what is happening, but appearance is 99.9% of reality. I don't necessarily believe that it would make it to a prosecution, but who wants that kind of scrutiny? It's better to stick within the scope of the agency's license and your own professional boundaries.