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Appropriateness for Home Health Care
Services:
What Home Care Providers Need to Know
By Elizabeth E. Hogue, Esq.
Both Medicare-certified and private duty home health agencies must manage their patient mix in order to be economically viable. Thus, all home health agencies must carefully control admission and continuation of services. Patients who are admitted who are not appropriate gobble up resources with an ultimate adverse effect on the ability of Medicare-certified agencies to provide care at a cost that is below the episodic payment and on the "bottom line" of private duty agencies. In addition, provision of services to patients who are inappropriate for home care enhances the likelihood of legal liability in this so-called "litigious society."
Consequently, staff must evaluate every patient for general appropriateness for home care services before they are admitted. Just because patients meet the criteria of payor sources, such as the Medicare Program, does not mean that they should be admitted. Likewise, patients must be continuously monitored in terms of these criteria. Patients who fail to meet one (1) or more of these criteria prior to admission should not be admitted. Services should be discontinued to patients who met these criteria upon admission but no longer meet them later.
In order to be generally appropriate for home care services, patients must continuously meet all of the following criteria:
- The patient's clinical needs can be met at home.
- The patient can either self-care or there is a paid or voluntary reliable primary caregiver to meet the needs of patients in between home care visits.
- The patient's home environment supports home care services.
The ability of home care providers to care for medically complex patients has been greatly enhanced in recent years. Consequently, it is relatively rare that the clinical needs of patients cannot be met at home. These rare instances may involve, for example, patients who are prematurely discharged from institutional settings
In addition, patients must be able to self-care or there must be a paid or voluntary reliable primary caregiver prepared to meet the needs of patient when agency staff members are not present. Staff may encounter very significant difficulties with this criteria as follows:
- When staff evaluate patients for admission, they will certainly
identify a potential primary caregiver. But, realistically speaking,
about all they can tell about potential primary caregivers during
the admission visit is that they are vertical and breathing. The
competence and reliability of primary caregivers can only be
assessed
over time.
- Staff members are also often working uphill against the
expectations of patients and their families. Specifically, case
managers/discharge planners in institutional settings are under so
much pressure to move patients out of the institution that it is
difficult to find the time to explain to patients and their families
what their role in home care must be. Consequently, patients often
are referred to home care with the expectation that nurses will take
care of everything, just like they did in the institution. This
expectation is further enhanced by the general lack of understanding
by many patients and their families about home care. In addition, in
the face of illness, it is only human for vulnerable patients and
families to want agencies to simply step in and take care of
everything.
- In addition, some of the tasks that primary caregivers may be expected to perform are repugnant to them. The "big three" such tasks are: (1) wound care, (2) changing diapers, and (3) giving injections. When these tasks are involved, the reliability of primary caregivers may be sorely tested. Case managers/discharge planners and agency staff members should be very specific about the tasks primary caregivers will be required to perform, especially the three mentioned above.
What can agency staff members do to increase the likelihood that they can identify capable, reliable primary caregivers?
- During the admission visit, staff should be very direct with
primary caregivers about the role they must play. If there is no
primary caregiver, services cannot be initiated in most instances.
They must further make it clear that if primary caregivers fail to
fulfill their role, services may be discontinued. This very direct
discussion and potential primary caregivers' agreement or refusal to
perform required tasks must be documented.
- If it appears that there is a reliable caregiver and the patient is admitted, staff must continue to monitor for reliability. Staff must specifically document every instance of noncompliance by primary caregivers. It is not sufficient to document that the caregiver is generally noncompliant. Rather, staff must document specific instances of noncompliance. Staff may document, for example, that they changed the patient's diaper at 2:00 p.m. and placed a red mark on the right tab of the diaper at that time. When staff returned the next day the patient was lying in excrement and urine and still wore the labeled diaper. Then staff must reteach primary caregivers and, if appropriate, get a return demonstration which, of course, must also be documented. This process should encourage reliability by caregivers.
Finally, the patient's home environment must support home care services. Documentation related to this issue is often provided in the form of safety in the patient's home. The term "unsafe" is very vague and can mean everything from too many scatter rugs on the floor to rats gnawing on intravenous (IV) tubing. So staff members should be careful to document that the patient's home environment will not support home care services for specific reasons.
Home care providers must, however, be cautious with regard to assessment of this criteria. First, there are many people who choose to live differently than home care staff members. So-called "path patients" illustrate this point. There is so much rubble and debris in the patient's home that workers can only pick a path from the front door to the patient's bedside. These patients, however, are not necessarily inappropriate for home care services.
In addition, our society is increasingly diverse. Home care providers must be prepared to accommodate this diversity without drawing erroneous conclusions about the appropriateness of patients' home environments. Staff members, for example, who provide services to patient on tribal lands or Indian reservations have encountered instances when patients and their families refused to answer the door when they knocked. Staff later learned that it was the custom in those tribes for visitors to wait in their cars until they were acknowledged in some way i.e. the raising of a shade or the opening of a door before they walked to the door of patients' homes. These were not homes that would not support home care services. Rather, these were cultural and ethnic differences that must be accommodated by home health providers.
When patients meet all of these criteria, it is appropriate to admit them for services. Patients who no longer meet them are not generally appropriate for home care, and services may be discontinued. Agencies ignore these criteria at their own risk.
Copyright, 2002.
Elizabeth E. Hogue, Esq.
All rights reserved.
No portion of this material may be reproduced in any manner
without the advance written permission of the author.
Elizabeth E. Hogue, Esq.
15118 Liberty Grove
Burtonsville, Maryland 20866
Office: 301-421-0143
Fax: 301-421-1699