For Home Health clinicians who have been working in the industry since the pre-PPS era, you know what I speak of when I state; 15 years ago, performing a BID or TID wet to dry dressing daily for weeks on end was the norm. While there were fewer options for the management of wound care at that time; the last decade has brought great improvement in wound products and techniques, such as the use of negative pressure in addition to teaching caregivers and families to assist homebound patients in the care of these wounds. Today, contemporary homecare interventions often train both patients and caregivers how to effectively manage them at home without nursing visits multiple times a day. As is often the case, what we provided years ago does not define our practice today; knowledge has increased, and the opportunity to provide efficient and safe care with good outcomes is now the order of the day. With an eye on the 2011 PPS Rule, we will examine how the rules have changed our approach from both financial and clinical aspects. As Med Pac and CMS continue to look toward the future of health care reform, and the delivery of homecare through anticipated ACO or bundled models is under review, we must ask: how has this impacted our nursing care plan production and delivery?
With the implementation of OASIS, care delivery models were to be based on the information gathered through objective as well as subjective assessments during the Start of Care visits. How efficient are your clinicians at assessing these findings? Do they have formal training on both OASIS and functional assessments? Do they understand that discharge planning starts on admission? Does the OASIS-based care plan truly identify and reflect the clinical severity and needs of the patient? How many clinicians understand the use of OASIS versus just another set of questions that need to be answered? Do they understand that the OASIS content is converted into a HHRG, and that they are effectively documenting for coverage? Have your clinicians internalized that, from an auditing perspective, this information not only tells the beginning of the story of the patient, but also delivers the content a quality auditor would expect to find in that medical record based on the severity ratings?
With the use of the “one size fits most” delivery model of many current Home Health nursing pathways, the individualized delivery of care based on specific needs and deficits that are derived from the OASIS often gets lost in the shuffle. All patients do not fit into the same model for obvious reasons. Let’s examine an actual case: a 78 year old exacerbation of CHF patient was just discharged from a 6-day hospital stay. The patient was admitted with severe fluid overload and required daily IV Lasix, Potassium replacement, and had +3 pitting edema to BLEs with a 15 pound weight gain. The patient was nutritionally depleted due to loss of appetite and developed weakness, he was described as lethargic and was severely SOB with minimal exertion. He had forgotten to take his diuretics at home BID as ordered, and was only taking them daily. He was not following his sodium restricted diet. He lives alone, is A&O x 3, and thought he could manage his care at home. He had initially been diagnosed with CHF 4 months prior, and had no previously-established medical conditions of note. He has a son who lives nearby, but did not want to bother him to do any extra work by coming over to help him, or take him grocery shopping. He decided to just finish up the cans of soup he had in the cabinet as to not bother his son. He was independent before this episode, did not drive, but definitely was not homebound. He returns home with 4 new medications, a 1L fluid restriction, daily weights, B/P monitoring, and strict sodium reduced diet. How many visits will he need? Have you had any similar patients on your recent caseload?
In this case, the agency taking this patient employs the use of care pathways, pre-determined nursing models based on diagnosis, which dictate that the patient is to be visited by the nurse 2wk4, 1wk5 (a certification period pathway in 2011? ). He scores out at a C3, and we know that he is going to need immediate evaluation and observation based on current status, not to mention intense teaching on meds, diet, fluid restriction, BP monitoring, and potential labs. Is the use of the pathway 2wk4, 1wk5 effective? Does this deliver the type of nursing care designed to be cost effective with high quality outcomes and low risk for re-hospitalization? Is this what the nurse would propose if she were treating her uncle on an unpaid basis? We admit the patient to service on Monday, and then what? Do we tell the patient that we will be back on Friday because that fits our schedule and still keeps us compliant with the pathway? How can you ensure teaching is adequate, educate the son as well, and have him involved in overseeing the meds, diet, weights, etc., to prevent the patient from making a mistake and being re-hospitalized? As we look at outcome based care that is delivered via the OASIS-based PPS HHRG model, how does this make sense? The “one size fits most” model does not apply. A more effective approach might be one based on the OASIS and definitive needs of the patient. In order to teach necessary prevention of CHF exacerbation; it may be more appropriate to deliver the care at 3wk4, decreasing the frequency with use of HHABN depending on the progression towards goals and stabilization of condition. If he is not able to manage these things, and has not stabilized by this point, then you need to ask yourself if there is an underlying medical condition, or is there a compliance issue? After all, how long does it really take to teach a medication; 9 weeks? Remember, his PLOF was independent. In addition, once we hit the 9 week marker, do we recert? If so, on what basis? If you haven’t taught the patient what he needs to know by now, or arranged for the support from family, community resources, etc, how can you expect to be paid again to do the same thing? A medication dose adjustment? By this time the patient should understand purpose, side effects, dose, etc. Another 9 weeks to teach a dose adjustment hardly seems either reasonable or necessary
Let’s turn the situation around, let’s say the patient is a 65 year old who had the similar diagnosis of CHF exacerbation, spent one night in the hospital for SOB, had his diuretic adjusted, and has stabilized. PLOF was independent and patient was driving; wife was present and helping with any needs. He had not missed a dose, just needed an adjustment and was in for 24-hour observation. He scores out as a C1. Same care pathway, but the “one size fits most” model would not apply in this case. Care delivery is OASIS based, and should be individualized to each patient. In the second scenario, how cost effective, and in accordance with the Medicare Benefit, would this case be if we scheduled him for 9 weeks of care, and kept him on service because that is what the pathway states we should do? Would you even admit this last case, and if so, on what basis? When a patient doesn’t qualify for services, what do your clinicians do? How do your clinicians respond when a patient achieves the goals of care? At the hospital, for example, when the patient stabilizes, the patient discharges. In home care when a patient reaches their goals of care – they are often not discharged. The premise for the home care model was not to “drop by and see you just because” – it is the delivery of short term and intermittent care based on Chapter 7 of the Medicare Benefit Policy Manual. Somehow these patients were functioning before we came in and provided skilled care. Despite the fact that we have achieved the goals of care through our clinical delivery and expertise, we often feel the need to continue to see them “just in case”. Patients don’t want to be patients. Hospital patients rarely, if ever, are heard to exclaim “I love being a patient here!” So why do we expect they would want home care to remain after goals are achieved?
As we dig out from the 2011 changes, and look toward the ACO/bundling delivery of care models; it becomes obvious what will be required. Nursing care delivery that is OASIS based, individualized to the deficits and needs of the patient to elicit high quality outcomes and low re-hospitalizations will be the winner here. Utilization management and effective development and delivery of the care plan are crucial. UR oversight and education on OASIS based care through supervisory staff is paramount. Clinicians will struggle to see the whole picture unless they are educated on the basis of the PPS care model. Efficiency, productivity, and effective programming will be the only path to future survival. 1995 may have been a good year, but things have changed. Clinicians often struggle with fear and discomfort of the unknown. A clinical delivery system independent of supervisory UR management is already headed down a dark path. The need for home care in the future is not going to disappear: but agencies with poor outcomes, lacking efficiency or productivity management oversight, and dependent on long term patients, will. Our delivery of care must evolve from what we did 16 years ago. CMS and Med Pac are revamping their goals of the PPS care delivery models, why aren’t you?
The HHSM Nursing Newsletter is written by Kimberly A. McCormick, RN/BSN, Administrator of Phoenix Home Care, of Burr Ridge, IL. Her expertise is based on sixteen years of homecare experience.