Updated: Nov 9, 2023
Published Nov 4, 2023
I am recently returned to home health nursing after a hiatus of 2 years. The agency I just started with is a smaller one and in the past two weeks I have learned quite a bit about the differences...this agency says they are Medicare-certified but we are mainly serving Medicaid and managed care patients. The reasons are quickly becoming obvious. There is a lack of clinical oversight and no billers/coders...the quality of the OASIS/Medicare data that is being sent out is not good enough to get reimbursed by Medicare. So we get alot of long term medication set-ups and mental health clients. My problem is with the wound care clients. I am a certified wound care nurse and take pride in my work.
The agency has basically provided me with no wound care supplies whatsoever. I was given a few pack of non-sterile gauze (already opened!) and two small bottles of NS. I was told these supplies were "donated" from former patients. The reason I was given is that we provide the skilled nursing/assessments but patients must obtain their own wound supplies from a DME with a provider's orders. I am sure you all know that for Medicare patients this is untrue and HH agency must provide the supplies, since we are given lump sum payment for an episode of care. And my boss agreed with me and said they will buy some more gauze! But they will not buy any tegaderm, foam, alginate, xeroform, contact layers or any type of advanced dressing, despite the fact that these advanced dressing are in fact the standard of care in many cases. For the Medicaid patients its even more grim because although I do have experience with getting providers to order DME, this is a process that can take several weeks. This can seriously impact chronic wound healing, as they could become infected or colonized while being sub-optimally treated with gauze or worse. And a smaller wound such as a skin tear or surgical wound could be healed with proper application of moist wound healing principles in the time it takes to get the supplies. I do understand that the dressings will not "heal" the wounds and many patients have other factors that are in fact more important such as nutrition, pressure relief, compression/elevation etc.
Wound care supplies were sometimes an issue at my former agency, and occasionally I would have to argue with someone at corporate about how Kerlix + Coban is not the same thing as two layer compression wraps. But I never imagined I would work somewhere that provided no wound care supplies to speak of whatsoever, and that even when my boss admits they should order supplies for Medicare patients they will not provide anything to Medicaid patients, thus creating a two-class system of patients?
America, this is getting really grim! We need a Single Payer System now. But in the meantime, does anyone have suggestions for how to get my patients some decent supplies? Or how to convince my boss to at least stock some Standard of Care supplies?
Oh, and also no provisions of PPE and standard precautions beyond VINYL gloves. No chux, no bag barriers, no alcohol wipes, no Cavi wipes, no gowns, no masks...the nightmare just continues.
So why are you still there? Not snarky but a serious question. Based on your post, it sounds like you really know what you're doing, the ins-and-outs of HH and Medicare and Medicaid, and a certified WC nurse on top of that! I think you need to take off. Running! Some agency will greatly appreciate your knowledge and acquired skills and jump at the chance to hire you.
Admittedly, I'm biased. Tried HH for a short stint and it wasn't for me. I never really "got it" in spite of years of nursing experience. I think in great part it was because I worked for 3 different mom-and-pop types of places that sound much like you've described. Unfortunately, decent and reputable agencies didn't want to hire me due to lack of experience. And really, I understand. HH is far more complex than some realize.
I would resign immediately; that agency has no business admitting patients to service when they're unwilling to provide what you need to fulfill physician orders. I've worked for 2 different private home health agencies; mgt bent over backwards to ensure we had all the wound care supplies we needed....if they didn't stock, it was ordered and we got orders from the MD for any substitutions needed. Have they ever been reported to the BON? What do they do when state surveyors come and go out on visits? Wow
Get a SOC folder.
Call complaint line.
In the mean time, follow the chain of command. Notify the MD of supply issues - let your boss's referral source call the office and ask why they need to waste their time with the phone call.
edit: Depending on how much trouble you are interested in causing, you can also double up on the regulatory agencies by reporting PPE issues to OSHA. Sounds like a bridge burning situation to me.
I work for an agency that deals with mainly Medicaid/managed care. The agency does not supply us with anything other than vinyl gloves and masks (N95 and surgical). We also get a bit more than for dressing supplies, but not much.
Patients who are set up with a wound care clinic usually get enough supplies to bring home with them for 1 dressing change. The day of their wound care appt I call in their supplies order and it takes 2-4 days for supplies to be received. If you have a medical supply company local to you then you can bring a copy of the wound care orders and have them filled in person.
Typically once I establish an account with the DME company (We use Byram) then re-ordering supplies is much faster and they usually come within 48 hours. Always add nitrile gloves onto the supply order!
For skin tears and other new wounds, you technically need an order to do any wound care anyways. I call the doctor, ask for an order for whatever dressing it is I want to do, and then tell them I'm putting in an order for supplies with x company. Byram is really good about verifying the order with the doctor the same day I order supplies.
Wound care supplies are expensive and your agency does not receive any money to purchase them for Medicaid patients. It's not a two class system, it's just insurance reimbursement differences. Wound care supplies are part of the payment received by the agency for Medicare patients. It sucks for us, but imagine eating the costs of those supplies for every single patient who doesn't have Medicare. The order I placed today was $1,200 for a one month supply of puracol, mepilex, Alginate, etc. That was just for one patient!
Thanks Cate this is a helpful comment. I'm trying to work with this system. Also using Byram.
By using the site, you agree with our Policies. X