The Intoxicated Patient
February 26, 2009
This week, I was visiting with a client and read a Resumption of Care assessment where the nurse had charted that a patient had, “a strong odor of alcohol, slurred speech and problems with balance”. I thought this was a very appropriate description of a patient who was ‘drunker than Cooter Brown’. Further on in the assessment that I noted very minimal, if any, impairment documented in the functional domain. The patient used a cane but was able to transfer, bathe, and dress independently.
This became a lively debate at the agency that day. The patient who had been on service long before his readmission was capable of living independently in the home. He had not been drinking prior to the hospitalization but had a history of alcohol abuse and liver disease. One nurse said that because alcohol impairment was temporary and he was able to perform these tasks on a regular basis, that the chart should reflect his usual ability more than fifty percent of the time.
Another nurse stated that the patient had a prior history of alcohol abuse that it was unlikely that this was an isolated event and thus the patient wouldn’t be safe the majority of the time in the future.
I just sat in the corner and wondered if ever the day would come when I heard everything. But as I thought more about the issue, it occurs to me that many patients are temporarily impaired on a regular basis, not just the occasional patient who abuses alcohol. This could be the result of pain medications or anesthesia/sedation after an outpatient procedure or varying abilities secondary to a disease process. Therefore, even though we don’t get many intoxicated patients, the answer was very important.
Here is what the OASIS manual, chapter 8 says about scoring the functional domain questions:
The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to do on the day of the assessment. If ability varies, choose the response describing the patient’s ability more than 50% of the time.
The time period being assessed is the day of assessment. So if a client is able to perform a task more than 50 percent of the time on the day of assessment, questions would be answered accordingly. A patient who awakens with pain in the mornings might not be safe to bathe or dress independently for an hour or so until pain medication takes effect but assuming the medications do not have side effects, the patient would be able to safely perform the tasks mentioned more than 50 percent of the day of assessment.
Conversely, a patient who is admitted following an outpatient procedure where strong sedatives were used might not be safe to bathe or dress independently for the rest of the day. In this case, the degree of functional impairment should reflect the patient’s ability under the lingering effects of sedation.
Patients taking powerful narcotic pain relievers might also be temporarily impaired. The key to answering the questions in the functional domain is how often the patient requires narcotic pain relief.
In recent clinical work, we have clearly uncovered the need for additional OASIS/PPS training. In the next week, we will be making available web based training for all clients and other interested agencies. Please email us at haydelconsulting@bellsouth.com if you have an interest in providing additional training for your clinicians.
As always, your comments, stories and questions are most welcome.
Hospitalization in the Five Day Window
February 23, 2009
In spite of careful planning on the part of nurses, therapists and physicians, it sometimes happens that a patient will go to the hospital after a recertification OASIS was completed and actually stay in the hospital for the duration of the episode and into the following episode. When this happens, it is frequently the case that the patient must be discharged and readmitted, but not always.
If a patient comes out of the hospital after the episode has ended and if (and only if) the patient has the exact same HHRG as the prior episode, only a resumption of care assessment is required. To determine if the HHRG is exactly the same, you may use the CMS toy grouper or PPSGrouper.com. Alternately, your software may have the capability or you can painstakingly compare answers with the last assessment while remembering that differing answers do not always result in differing HHRGs.
If the HHRG does differ then the patient must be discharged and readmitted to the agency. In order to accomplish this, most agencies begin a new chart. This is also problematic because often times, the second chart appears to be incomplete. For instance, you may have a situation with unstable caregivers that has previously been addressed by your social workers. In the new chart, all a reviewer may see is the unstable caregiver situation without reference to any intervention. Therefore, our suggestion is that when you must readmit a patient due to intervening hospitalizations to always reference that this is a readmission due to OASIS considerations. This allows your quality assurance department, your surveyors and reviewers and most importantly your consultants to understand that a prior chart with additional information does exist.
A document that addresses OASIS Considerations for PPS has been linked under the Essential Links section in the sidebar to your left. As always, we welcome your comments or your emails at haydelconsulting@bellsouth.net.
Low Tech Telemedicine
February 16, 2009
An enormous amount of health care dollars are spend every year on high dollar telemedicine technology with the goal of improving patient care. We support technology in health care. It is clearly the way of the future and any and all tools available to agencies should be employed when they promote communication and patient care.
But before your agency purchases high dollar equipment, are you completely sure that all technology currently available to you is being used? What about the expensive telephone system that decorates your office?
In determining frequencies, we generally try to establish how often the patient will require visits by the clinician. Most Clinicians, in an effort to err on the side of caution, will schedule generously. What many agencies have already discovered is that certain follow-up tasks can be accomplished with a short phone call in lieu of a visit.
Consider a newly diagnosed diabetic patient who is seen five times in succession on the first week of admission with plans to reduce visits to twice weekly after the skill of blood glucose monitoring is mastered by the patient. At the end of the fifth visit, the patient is able to independently perform the skill but is still a little unsure. The nurse might very easily perform a sixth visit to ensure that the patient is comfortable performing a new skill. Or, maybe, all the patient really needs is a little reassurance in the form of a telephone call.
This same logic applies to reducing frequencies at time of recert or after an acute exacerbation. It isn’t necessary to drop cold turkey to a lower frequency. A phone call to check on the patient between visits goes a long way to ensure the nurse that the correct clinical decision has been made. And obviously, should a need become apparent during a phone call, an additional visit can always be added to the schedule.
Other phone calls I would like to see made include:
- Phone calls after visits missed due to no answer to locked door.
- Phone calls after MD visits
- Phone calls when there is a change in caregiver situations at the house
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Follow up after the beginning of a new medication or the cessation of a long term medication
Of course, all the phone calls in the world won’t go far to protect you in a survey or payment review situation. But considering that care coordination deficiencies are among the most commonly cited survey deficiency, the process of making phone calls and including documentation in the clinical record can go far to show the quality of care your agency gives.
To make it easy for nurses to improve care coordination through low tech telemedicine techniques, clean and uncluttered forms should be available. Consider including a stack with weekly schedules. Add checkboxes for physician and interdisciplinary communication to ensure that coordination is well documented.
