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Difficult Decisions


Be honest with yourself.  Have you ever held on to a patient longer than they technically qualified for home health services because there was nobody else to take care of them?  Have you ever recertified a patient for diabetes because they had an isolated blood sugar of 302 after washing birthday cake down with coke? What about the patient who has achieved stability at rock bottom and the only alternative for the patient is a nursing home?

I can spot patients who do no longer meet Medicare coverage guidelines a mile away because of my superpowers.  Also, I am not emotionally attached to your patients so it is easier for me to be objective.

These are the facts and I do not like them one little bit:

  1. Observation and assessment is a skill for only a short period of time (generally 3 weeks) unless there is documentation to support why the patient remains at increased risk.  This means stuff like actual falls and changes to the plan of care.  Headaches during allergy season that are controlled with Advil do not paint a picture of increased risk.
  2. Teaching is a covered skill.  Re-teaching is only a skill if there is a documented reason why said re-teaching was indicated.  Teaching is NOT a skill when it becomes apparent that the patient cannot or will not learn.  This means that teaching an advanced Alzheimer’s patient new skills will not be deemed reasonable and necessary.  It does not matter how hard you teach someone who is unable to learn.
  3. Homebound status is very poorly defined unless you work for someone with the authority to deny your claims.  Document homebound status.  If the patient meets homebound criteria three ways, document three times.  Everyone is SOB with enough exertion.
  4. There is a space at the lower left corner of each 485 that reads, “Attending physician’s signature and date signed”.  A Nurse Practitioner, physician assistant or love interest of a physician is not a physician.  When you identify actual physicians, try to narrow your choice down to the one who actually attends to the patient’s need and obtain their signature.  A signature is when somebody write their own name in their own handwriting or uses a secure electronic alternative.  Don’t stop yet.  Get the DATE.  If you haven’t heard me rant about dates yet, it is because you haven’t been paying attention.   
  5. Sadly, home health aide services do  not qualify a patient for home health.  In the event that you admit a patient who will likely require services indefinitely, that is the day you should begin searching for an alternative. Call relatives.  Beg churches.  If the patient  has Medicaid, find waived services for the patient.  Anticipate the day you will have to leave your patient alone in the house because there are no more skills to render.

It is heartbreaking to discharge some patients.   Sometimes it helps if another nurse goes to do the dirty work.  I have taken the discharge of patient in need of services not covered by Medicare harder than I ever took a death in all my critical care years.  There’s nothing left to do for a patient at room temperature.  Lonely elderly folks with vital signs are the ones who turn my heart to mush.

Knowing what constitutes skilled care going into the house will guide you in seeking alternatives to what feels like abandoning a patient in need. Remember, the folks who do ADR’s and ZPIC reviews do not know how sweet your patient is.  They have not been seen how happy your patient was to share with you the cookies someone made for them at Christmas.  They have not heard about the way music used to be played when it was good or held your patient’s hand when they lost a spouse.  If you are a good nurse, a patient will touch your life as much as you touch theirs.

But, none of that sappiness, as real as it in our hearts will keep you out of trouble if you do not provide skilled services according to Medicare guidelines.  When you fail to follow guidelines, you put at risk all of your patients, your employees or employers, their families and the agency’s stakeholders.  Better just to start planning your exit strategy on admission, wouldn’t you think?

If you have any questions, please contact us or post below.  If you want to hire Haydel Consulting Services to discharge your lonely patients, we will be glad to do so.  Just take our regular hourly rate and multiply it by 72,761 and plan on a 50 hour minimum for discharge services.

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