“My question regards discharging a homecare patient if they demonstrate non-compliance. In previous articles, you specifically used PT non-compliance as an example. What is nursing’s role if PT does, in fact, discharge? We have a lot of patients that are re-admits for variations of the same diagnosis and if they aren’t compliant with their PT Plan of Care and therapy ultimately discharges as a result, the nurse continues her Plan of Care and then, eventually discharges. We currently have a patient referred for the 3rd time in a year with a diagnosis of weakness; they are again refusing PT. The client had therapy in previous episodes but the issues this time are essentially the same as they have been in the past. Nursing is re-teaching everything that had been done in previous certifications and assessing for anything new, but we anticipate ongoing referrals over and over again with only the same failed issues to address. What happens when that patient gets re-referred to us with the same diagnosis and the same therapies ordered as the previous time?”
The issue of patient participation and compliance has become increasingly relevant in the home health industry as we move steadily towards the Pay for Performance era. The clinical basis of this OBQI-based P4P method is patient improvement in the twelve outcome categories tallied and posted on Home Health Compare. Successful agencies are those that are able to demonstrate functional patient improvement; that is, agencies that get their patients better.
We must not take for granted the recent emphasis on actually “getting the patient better”. Though all of us in homecare truly desire good clinical outcomes, the specific programming required to realize such goals in our patient programs often takes a backseat to our daily routine and other home health nuances, such as documentation, agency policy, working habits, etc. Recent articles (Patient Refusals during SOC programming-6/16/08) have emphasized that the job of the Start of Care clinician is to not only identify the services required for good clinical outcomes, but to get the client to accept the services. Your question relates to the next step in the process; client participation and ultimately, compliance required for a successful homecare program.
Before reviewing the appropriate steps that should be taken to address ALL non-compliance issues, we must point out that we are not seeking to discharge any individual client from their Medicare home health program. Rather, we are following the CMS regulations and enforcing the programming ideals as a means of soliciting the behavior required to achieve success under the current PPS-based homecare model. As clinicians, we not only know what each discipline adds to the program, but also how specific clinical services achieve their desired outcomes. Remember, physicians, patients, families and caregivers all may need ongoing education in order to offer support in these areas.
The patient you describe has had previous episodes that have been un-successful as a result of the history of non-compliance with PT. Your first question in this instance asks if nursing should stay in the home and complete their Plan of Care programming after PT discharges due to non-compliance. Nursing and PT should ALWAYS stand alone with regards to care issues. This isn’t to say that these two disciplines cannot co-ordinate care or provide separate contributions to the same problems. Rather, the disciplines should complete their respective Plans of Care in timely manners and then discharge promptly. Nursing should complete their POC after PT discharges and should discharge when goals are met or deemed unattainable. If the client is compliant with the nursing POC, hopefully, goals will soon be met. If they are non-compliant with the nursing POC also, discharge is appropriate. In any case, nursing should not remain in the home for the sole purpose of waiting for PT to discharge.
Next, you recount the multiple un-successful episodes this client has had this year based on non-compliance. The latest re-referral for the same problem has nursing re-teaching in areas that have been previously addressed but not resolved due, again, to non-compliance. In this instance, the Start of Care clinician must identify needed services (sounds like Physical Therapy here) and address the lack of performance in previous episodes and what steps the client will take to prevent the same result. If the client declines PT, the nurse only opens the case if NURSING care deficits are present that can be addressed with an expectation of achievable goals. If therapy needs are the only clinical deficits noted, the client would not be opened to the agency upon refusing PT. If the referring physician is unable to convince the client to accept PT and participate with the program, no homecare program would be provided. If the physician insists that some type of service be in the home, the Advance Beneficiary Notice must be engaged to assure CMS that provided and billed services may not meet Medicare requirements.
This example allows the author to re-state that under the PPS New Rule (and the upcoming P4P era) the only basis of clinical and fiscal success will be the ACTUAL improvement of patient function or well-being. Agencies who continue to re-admit the type of patient you described will have unsuccessful outcomes, poor financial results, and unhappy clinicians.
Arnie Cisneros is a physical therapist with nearly 25 years of home care experience. He is the owner of Home Health Strategic Management in East Lansing, MI, providers of clinical service management and home care consulting expertise. He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule.