chapter037homehealthnursing-090818190639-phpapp01

REIMBURSEMENT ISSUESMosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
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Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
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Bathroom
Kitchen
Code Team/ ICU
Home Care
Facility Care
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Home health nursing services enable individuals of all ages to remain in the comfort and security of their homes while receiving health care.
Family support, familiar surroundings, and participation in the care process contribute to feelings of worth and dignity.
Services may include skilled nursing, physical therapy, speech language therapy, occupation therapy, social services, intravenous therapy, nutritional support, home health aide, respiratory therapy, acquisition of medical supplies and equipment, and homemaker and companion care.
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Appointments
& School
Supply
Acquisition
Nutritional
Needs
Case
Manager
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Educating the patient in the home setting.
(From Potter, P.A., Perry, P.G. [1997]. Fundamentals of nursing: concepts, process, and practice. [4th ed.]. St. Louis: Mosby.)
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Official
Services are provided to individuals and their families in their place of residence for the purpose of promoting, maintaining, or restoring health or of minimizing the effects of illness and disability.
Patient
Skilled and compassionate care is provided on a one-to-one basis in the comforting and familiar surroundings of the home.
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In the home, the nurse encourages the patient to use imagery to relax and relieve pain.
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)
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Family
It is a means to keep the family together as a functioning, integrated unit.
Provider
All disciplines involved are challenged to provide excellent care in often less-than-excellent conditions and surroundings.
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Advocacy
Physician
Home
School
Travel
Medications administration
Supplies
Call Pharmacy as needed. Pick up meds PRN
Physician
Letters of medical necessity Prescriptions
Schedule appointments Arrange Transport
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Home care was formerly defined as simply providing physical care to the sick in their homes, but the scope and complexity of the concept and practice have grown.
Roots of the concept can be traced to the New Testament of the Bible, which describes visiting the sick as a form of charity.
The first home health care program in the United States was organized in 1796 as the Boston Dispensary.
The first visiting nurse service in the United States was formed in Philadelphia in 1886.
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Lillian Wald and Mary Brewster developed a visiting nurse service for the poor in New York City in 1893 at the Nurses’ Settlement House on Henry Street.
In the 1800s and early 1900s, visiting nurse associations were formalized, and public health departments became widespread.
The Social Security Act of 1935 first provided government rather than local charitable funding for selected services such as maternal health, communicable disease, and the training of public health professionals.
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When Medicare became effective in 1966, it revolutionized home care by
Changing it to a medical rather than nursing model of practice
Defining and limiting services for which it would reimburse
Changing the payment source and even changing the reason home care was provided
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Diagnosis-Related Groups (DRGs)
Congress enacted this prospective payment system in 1983 as a part of the Tax Equity and Fiscal Responsibility Act for hospitals receiving Medicare reimbursement.
Based on major diagnostic categories, a set rate is paid for the hospitalized patient's care rather than the “cost” or charges traditionally billed by institutions.
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Diagnosis-Related Groups (DRGs) (continued)
The net effect of the change was a major shift of patients out of the hospital into their homes, extended-care facilities, or skilled nursing facilities.
This created a challenge in terms of volumes of patients seen, necessity of more skilled nursing care over intensive times, and the evolution of highly technical procedures in the home.
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Agencies may have to comply with federal, state, and local laws and regulations via the following
Licensure by the state
Certification by the state certifying body designated by the federal government
Certificate of need granted by some state according to rules and formulas devised by state regulators
Accreditation by an outside agency that evaluates how well the agency meets certain standards set by the accrediting organization
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Location: freestanding or institution-based
Governance: private or public
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Voluntary
Official
Combination
Hospital
Proprietary
Other
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JCAHO is looking for agencies to establish ethics committees to handle issues that arise in the home.
Psychiatric nurse clinicians are being reimbursed by Medicare for home visits.
Social workers are taking a more active role in home health care.
More home health agencies are employing nurse pain specialists to assess and manage pain control in the home.
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Most agencies are obtaining a separate Medicare certification to provide hospice care.
Pet care programs are emerging to reduce stress for the home health patient who is too ill to care for his or her pet.
Electronic home visits may be evolving.
One of the most rapidly growing segments in home health is home infusion therapy.
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This is provided and directed by currently licensed registered nurses.
Basic nursing services may be provided by the LPN/LVN under the supervision of the RN.
Service goals
Nurses practicing in the home setting must be technically proficient, self-motivated, innovative, and independent decision makers.
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Role of the LPN/LVN
Skilled service has become a growing field of practice for the LPN/LVN as agencies cope with increased staffing needs, nursing shortages, and recognition of the contributions the LPN/LVN can make to home care.
Independent practice is not allowed, but self-direction, motivation, creativity, clinical proficiency, flexibility, compassion, empathy, and patience are all essential attributes.
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Physical Therapy
Services must be provided by a qualified and licensed physical therapist.
A physical therapist’s assistant may deliver limited services under the supervision of the licensed therapist.
The goals of treatment must be restorative for Medicare reimbursement but may be maintenance or preventive for other payer sources.
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Speech-Language Therapy
Speech services must be provided by a master’s-prepared clinician who has been certified by the American Speech and Hearing Association.
Therapy goals include minimizing communication disorders and their physical, emotional, and social impact.
Independent functioning and maximum rehabilitation of speech and language abilities are primary treatment goals.
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Services deal with life’s practical tasks.
The therapist will choose and teach therapeutic activities designed to restore functional levels.
Services include
Assessment for vocational training
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Medical Social Services
Services are provided by social workers prepared at the master’s level.
Focus is on the emotional and social aspects of illness.
The care plan includes education, counseling, payment source identification, and referrals.
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Homemaker-Home Health Aide
The aide provides the basic support services that can enable an elderly individual, disabled adult, or dependent child to remain at home.
Most aid services fall into one of three categories
Personal care
Physical assistance
Household chores
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Referral
Entry point into the home health care system
Can come from the patient, family, social service agency, hospital, physician, or another agency
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Admission
The initial evaluation and admission visits are made by an RN within 24 to 48 hours of the referral.
The evaluation and admission process generally includes at least the following.
Complete patient evaluation
Assessment of the family or significant other support system
Determination of knowledge and adherence to treatments and medications
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Determination of desire for care and services
Involvement of the patient and family in the development of the plan of care and goals
Notification to the patient of rights as a patient, along with costs, payment sources, and billing practices
Explanation of the patient’s right to self-determination
Provision of initial nursing interventions
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Care Plan
The physician must be contacted for specific orders before delivery of care.
A treatment plan is drafted cooperatively with the physician.
The plan describes the current physical status of he patient, medications, treatments, the disciplines needed to provide care, the frequency and duration of services, the goals/outcomes, and the time frame for implementation.
It must be signed by the physician and serves as the traditional physical orders.
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Visits
Visits for interventions by ordered disciplines are made to meet the patient-centered goals and progress toward identified outcomes.
Patients may be visited as infrequently as once a month to several times a day; several visits per week are typical.
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Documentation
It may be hand-written, dictated, or entered into a computer.
Many agencies are beginning to use various problem classification schemes linked with nursing diagnoses, specific interventions, and defined patient outcomes.
It provides an accurate picture of the type and quality of care and reflects the effectiveness of the plan of care and progress toward goals and outcomes or the reason for lack of progress.
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Planning begins with admission.
When patient goals or other specific criteria are met, the discharge occurs.
The purpose of discharge planning is to promote continuity of care in the patient’s home.
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This provides documentation for outside organizations and for internal measures of improvements and refinements of policies and procedures.
Three major elements
Structural criteria
Process criteria
Outcome criteria
Quality assessment plans reflect standards, objectives, and measurable outcomes and include plans for remediation or improvement as an integral part of the process.
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Medicare
This federal program requires agencies to be certified as meeting the federal conditions of participation, which set forth specific requirements for organization, staffing, training, types of services covered, and agency evaluation.
Beneficiaries of services must be 65 or older, disabled, or have end-stage renal disease.
Must be under the care of a licensed physician, homebound, and in need of skilled nursing therapy services
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Medicaid
This pays for home care services to indigent and low-income people of all ages.
It is administered by the state but is both state and federally subsidized.
Services vary from state to state, but most include the basic services covered by Medicare plus expansion of aide and personal care services.
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Coverage, requirements, and payment rates vary.
Reimbursement is often tied to post hospitalization recoveries.
A case manager will determine and arrange for a mix of home care, therapy services, counseling, supplies, and equipment for a patient.
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Private Pay
Individuals may also pay directly for home health services. Charges may be the standard full charge or may be scaled down based on ability of the patient to pay.
Other Sources
Health maintenance organizations (HMOs) and preferred provider organizations (PPOs) have negotiated contracts with home health agencies to provide services to their patients.
Both are prepaid health plans operated independently or through employer groups.
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Nurses encounter great diversity in a variety of cultural interactions.
Culture is present in the lives of patients, families, and health care providers and is especially apparent in the home environment.
Nurses need to anticipate potential cultural problems and identify their own and other’s values.
Cultural health practices may be incorporated into traditional medical care in the home environment, provided it does not conflict with the prescribed treatment.
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Disturbed thought processes
Ineffective airway clearance
Risk for impaired skin integrity
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Knowledge, deficient
Risk for injury
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Do Not Cross out or scribble. DO not write error
NO Transcription of numbers or letter
( tracing over to change a number is not allowed)
X
X
error
X
strode
k
X
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Current trends support the growth of home care as an economical, humane, preferred health delivery system for many types of care.
Home care provides needed assessment and evaluation of chronic illnesses to prevent acute episodes.
Aides and homemakers can provide necessary support in activities of daily living to enable the patient to remain in the home.
Skilled nursing and therapy offer rehabilitation and prevention of deterioration, as well as methods to cope with physical changes.
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Home health care allows individuals to maintain personal control and to participate in the direction of their personal care.
Families are an important part of the success of home care services as home care workers provide care, supervision, assistance, and support in attaining the care plan goals.
Home health care is not a new concept; however, legislative, regulatory, and current health care trends have changed the way it is provided.
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A number of different professional and paraprofessionals disciplines provide home care services based on coordinated plan of care of approved by a physician. Teamwork is an essential component of the concept.
Home health agencies are organized groups that employ or contract with professionals and paraprofessionals to provide services. Different types of agencies may be subject to varying federal, state, and local laws and regulations.
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Skilled nursing care is the most frequently provided services. RNs and LPNs/LVNs under the supervision of the RNs provide direct care of different levels of complexity.
Providers of care in the home must possess special qualities to effectively practice in this nontraditional environment.
Home health care agencies strive to provide the highest quality of services economically. Success is evaluated through quality assurance plans.
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Home health services are reimbursed by federal, state, local, group, and private sources.
Although some aspects of nursing interventions in the home are the same as those practiced in other health care setting, home health care nurses pay particular attention to interaction and cooperation among family members, the patient, and other members of the health care team.
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The acuity levels of patients requiring care in their homes continues to rise, and the technological equipment, including use of mechanical equipment and invasive procedures such as intravenous therapies, are increasing in home care. These factors, when combined with shorter hospital stays, require extensive discharge planning to prepare patients and family for home health care.
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First of all, let’s discuss what constitutes a reasonable and necessary skilled nursing service. To be covered, the services must require the skills of a nurse, must be reasonable and necessary to the treatment of the patient’s illness/injury, and must be intermittent. A skilled nursing service is a service that must be provided by a nurse to be safe and effective.
In determining whether a service requires the skills of a nurse, you must consider the inherent complexity of the service, the condition of the patient, and accepted standards of medical and nursing practice.
What is a Skilled Homecare Need?
A skilled need for homecare services is a requisite for services, payment and continuation of care,
including obtaining additional auths .A skilled services is one needing a nurse to perform or oversee.
Tips: Skilled visits generally to assess, observe, instruct, and perform!
A SDD is NOT skilled…however it may be skilled to observe the wound weekly or instruct CT to perform
wound care, otherwise a SDD is a red flag that the wound care is NOT skilled.
A Lab is Not Skilled…however...if the abnormal lab affects a recent unstable condition or med change
the assessment, observation and instruction is skilled.
SKILLED NEEDS INCLUDE
• Recent new or exacerbated diagnosis
• Change in medications in the last 60 days/New medication in the last 30 days
• Change in primary caregiver providing care with a knowledgeable deficiency
• Medication administration (other than oral)
• Wound care
• Mental status changes
A patient may require physical or speech therapy due to one or more of the following:
• Recent marked decline in functional status (i.e. speech, ambulation, strength, endurance)/Change in
functional status;
• Recent falls, fractures, stroke
• Need for home maintenance program to maintain current level of function
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QIs changing a suprapubic catheter a skilled nursing service?
A Yes. According to the Medicare Home Health Services Criteria, insertion and sterile irrigation and replacement of catheters, including care of suprapubic catheters and (in selected patients) urethral catheters, are considered to be skilled nursing services. When the catheter is necessary due to permanent or temporary loss of bladder control, skilled nursing services that are provided at a frequency appropriate to the type of catheter in use would be considered reasonable and necessary. Foley catheters generally require skilled care once every 30 days and silicone catheters once every 60–90 days; however, complications that require more frequent skilled care related to the catheter, with adequate documentation, would be covered.
What is a Skilled Homecare Need?
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would be covered.
QCan a patient receive hospice services along with home health services? A Although patients receive hospice services under the Medicare Hospice Benefit, they continue to be covered under traditional Medicare for healthcare services not related to the terminal illness. So, a patient can receive hospice services
along with home health services if the home health services are unrelated to the terminal illness. For example, a patient elects the Medicare Hospice Benefit, and his or her terminal diagnosis is endstage congestive heart failure; the patient also had a hip replacement and requires physical therapy to recover from that surgery. You could provide hospice services for the terminal diagnosis of end-stage congestive heart failure and any related complications. You could also provide home health
services for physical therapy related to the hip replacement, as the two are unrelated. One word of caution, though: Be very meticulous regarding deficiency may be issued based on a state regulation that is reflective of language based on the Medicare Benefit Policy Manual.
PDA WAIVER/ OPTIONS, WOUND CARE CLINIC, dialysis, chemo,
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HOW
MANY
VISITS?
How to determine appropriate visit patterns How much care do they need?
The number of visits you plan for a patient will match the level of care and instruction that patient will require. This is highly individualized to the patient’s needs. A new insulin dependent diabetic may require visits 3-4 times a week until independent with testing and self administering shots. Catheter changes or b-12 injection require just one visit a month, if unsure how to set a visit pattern, your team leader would be happy to help you plan one out.
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What happens when I cant find my admission or a patient doesn’t answer the door/calls
How many attempts do we make?
Did you call the faculty they were coming from, their contact listed on the mailer?
Did you call the doctor? You need to report all missed/refused visits and non admits to the doctor.
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Assess the home upon admission and routinely for Safety Factors, problems and needs:
Assess the clients home for Safety issues.
Body Mechanics for client and Staff
Is the clients bed safe is it a good height for the client and nurse
Bathroom safety: Bars , commode lifer, non slip surface mats
Kitchen Safety: safe stove , pot handles in, burners working
Are extension cords safe or a fire hazard ( frayed, worn, over loaded)
Does the client have a working phone
Does the client have electric and running water
Are smoke and fire distinguishers present
Are the medications stored separately, with in dates and not expired, out of reach of small children and elderly
Are floors clear of clutter, throw rugs to prevent falls and tripping accidents
Lifting safety? Is the client able to walk, transfer or do they require a lift.
Ramps and house access for disabled
Abuse Risk assessments elderly, small children and disabled
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Medicine safety lids and out of reach
Poison control hot line # present
Bed rails or crib rails, gates up
Tub safety, never leave unattended
Water temp checked prior to bath
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Nurses give report and get report
Please indicate who you picked up the client from and how you received report
Please document whom you left the client in care of .There is a box for this on the flow sheet at the bottom.
Family or client must sign flow sheet at the end of shift.
Samples:
1) Baby Billy was received in the care of mom. Mom States Baby Billy had a good day with O2 sats at 98%.
2) Jimmy Joe was received from Nurse Nancy. Verbal report given.
3) Karen resting in bed, side rails up, no apparent distress noted.
4) Suzie Q was left in care of Uncle Sam and resting comfortably in bed.
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All equipment should be cleaned and maintained. Sanitation of equipment is done by wiping down equipment daily and then soaking equipment for 20 minutes once a week in a
10 % solution of vinegar and water.
(1oz vinegar to 10 oz water)
Submerge items in solution for specified length of time 15-20 minutes twice week.
Remove disinfected items from basin and rinse in water.
Air dry or dry with paper towels before storing.
Store in clean, dry, dust-free environment, e.g., plastic, ziploc bag,
or lidded jar .
. Discard solutions into toilet, wash basin with soap and water,
rinse and dry with paper towels.
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Respect family wishes
Full code- initiate CPR and call 911
If the DNR (signed by MD ) is NOT in writing, it is a FULL code no matter what the family wishes are.
“NO CODE” support and respect client
Post mortem care per family wishes
WHO TO NOTIFY:

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