Admission Agreements to Establish Relationships with Home Care Patients

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Use of Admission Agreements to Establish Relationships with Home Care Patients

By Elizabeth E. Hogue, Esq.

Establishment of relationships between agencies and patients is a prerequisite to liability. Unfortunately, the home health model of care precludes the use of criteria like the patient's entry into a health care institution to determine when the provider-patient relationship is created. Home care providers must, therefore, develop other mechanisms for controlling both the beginning and end of relationships with patients. When agencies fail to control the establishment and termination of the provider-patient relationship, the potential for legal liability is greatly enhanced.

So providers must ask and answer some crucial questions, including: When should the provider-patient relationship begin? Are agencies responsible for patients from the moment they receive referrals? Is the staff responsible, for example, for patients who are referred via fax at 4:00 p.m. on Friday afternoon?

Clearly, the most appropriate answer to these questions is that home care providers should establish relationships with patients only after they have an opportunity to assess patients' appropriateness for home care. Otherwise, home health agencies will assume liability for patients who they have never seen and over whom they have no control, a very risky proposition.

Of course, many patients' and referral sources expectations are exactly the opposite. That is, they anticipate that home care providers have agreed to provide services upon receipt of referrals and will take care of everything even before staff has a chance to evaluate patients. These expectations were reinforced by cost-based reimbursement under the Medicare Program when agencies were rewarded for admitting as many patients as possible and providing as many visits as possible to them.

Staff must directly confront these expectations. Visiting staff should tell patients and their families upon arrival for the first time at the patients' home that they have not agreed to provide care for the patient. Rather, staff members are in patients' homes to assess patients for appropriateness for home health services. If the assessment reveals that the patient is appropriate for home health care, the patient will be admitted. But if the evaluation shows that the patient is not appropriate for home care, the patient will not be admitted and agency staff will not provide services.

Staff should then assess patients. Patients should not be asked to sign any documents such as a consent to treatment or acknowledgement of the Patients' Bill of Rights until after the assessment is complete.

This practice is directly contrary to the procedures advocated by many surveyors. But surveyors' insistence on a this particular practice that cannot be supported by Conditions of Participation (COP's) has the effect of subjecting agencies to increased liability because it forces agencies to establish the provider-patient relationship before proper assessment is completed.

The rationale given by many surveyors for this practice is that consent is required before staff "lays hands on" patients. Such reasoning is not supported by the law. In fact, the law regarding consent to treatment clearly indicates that no informed consent is required for routine types of treatment, including physical assessment. In addition, consent is implied when staff members are admitted to patients' residences and patients follow instructions to allow staff members to complete assessments for possible admission to the agency.

Assessments performed by staff should be comprehensive and include:

Patients' clinical condition.
Patient's ability to self-care or the availability of a reliable primary caregiver to meet the needs of patients in between visits by agency staff.
Whether the patient's home environment will support home care services.

If this comprehensive evaluation indicates that patients are appropriate for home care services, patients should be asked to sign an Admission Agreement.

"Admission agreement" may be an ominous term for providers in the sense that they may envision a long, complex document. On the contrary, Admission Agreements should usually include a combination of the various forms agencies use upon admission, including the agreement to pay, consent to treatment, acknowledgement of the Patients' Bill of Rights, etc. All of these forms should be combined into one document that is called the Admission Agreement.

Some providers are tempted to call this Agreement something else. This temptation should be avoided because the point of the agreement is to serve as evidence that the provider-patient relationship has been established.

The use of Admission Agreements should be accompanied by an agency policy and procedure that makes it clear that only patients who have signed Admission Agreements are the responsibility of agency staff.

If, however, staff members determine that patients are not appropriate for home care, then no Admissions Agreement should be signed. Patients should be told directly that they are not appropriate for home care and that agency staff will not return to provide services to patients. Needless to say, the fact that this information was conveyed to patient must be documented.

Field staff should also:

Notify referral sources and attending physicians that patients are not appropriate for home care services and document that they have done so.
Call 911 and ask for transport of patients in need of immediate care to the emergency room. Patients who decline transport are likely to have assumed the risk of any injury they may suffer.

Historically, agency staff members have sometimes acted from the point of view that something in the way of health care services is better than nothing. This tendency must be resisted at all costs. When home health agencies undertake care that is inappropriate, the risk of legal liability increases substantially.

(A book entitled Legal Liability will also assist providers to understand the issues covered in this article. It can also be obtained from our offices for $25.00, including shipping and handling.)

Elizabeth E. Hogue, Esq.
15118 Liberty Grove
Burtonsville, Maryland 20866
Office: 301-421-0143
Fax: 301-421-1699