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Filling in the Gap


Why should you be concerned about the penalties hospitals are facing for readmission? Because in many ways, you are the key to reducing them. A common theme that runs through editorials about rehospitalizations is the powerlessness hospitals and physicians face when discharging patients to the great unknown – home. Here is a great account from an ER physician snagged from the NPR website. Dr. Lena Wen painted a very real picture of the gaping hole between the hospital and the home.

In it, Dr. Wen takes the reader through a typical day in the ER where she works as a physician. She saw a woman with a pain in her gut for years but finally decided to see someone – the ER doc who found that she was depressed and was considering shooting herself with her husband’s gun. She wrote about a ten year old boy who lived in a house with smokers next to an interstate who suffered from asthma. His backpack was home to several expired inhalers and empty pill bottles and candy for lunch. There was an 80 year old woman who had fallen and a gentleman who was detoxing from pain medications. In other words, the doctors and hospital staff are very much aware that much happens in the home that they are not able to address. That should be okay. Home health and hospice workers know even more of the social and economic issues facing patients than the docs do.

Where home health, hospice and our payor sources fall short is in recognizing the value of home health and hospice in mitigating the risks in the home. Strict adherence to Medicare coverage guidelines has narrowed the focus of home health workers to the tasks spelled out on a care plan. A therapist fights for every visit they get. They do not take the time to investigate why a patient might seem to feel ‘blue’. Computer driven documentation is directing care resulting in nurses and aides missing cues to investigate. A patient mentioning they are hungry might mean that it is close to lunch; or it may mean that there isn’t enough food. It shouldn’t require a software prompt to find out but nurses have been conditioned to dread the consequences of an incorrect OASIS response to the extent that they almost never sit back and relax with a patient anymore. That should happen more. Regrettably, it does not.

It may be time to do something different. Maybe the involvement of other resources can help fill in the gap between hospitals and home. I’ll start by providing some contact information for National Organizations that can help you help your patients. You can complete the list with local services. If I were queen of the world, your list would be part of your Emergency Preparedness plan to be reviewed with every patient at the time of admission. Since this hasn’t been happening, it would be a great insert for a Christmas Card plus a part of your Emergency Preparedness plan. By universally distributing and reviewing the list with patients, a door is opened for discussion without intruding in the life of a patient who isn’t ready to disclose ’embarrassing’ facts about their life. It may also be an idea to invite representatives of various local agencies to visit you and your staff so there is no misunderstanding about services provided. Home health aides should be included because they are often the first point of contact when patients share sensitive information. So, click on the links and get to know these National Services and then add your own to it and let me know when you have finished. Just kidding. I’m not in charge of this project. You don’t have to answer to me.

NeedyMeds is a groovy cool website that provides easy access to all the patient assistance programs that might help a patient cover medications. Other ways to save are also offered. So when a patient cannot afford a medication, print the appropriate forms, get the patient’s information and then take it or fax it to the MD for the final touches. When you are at the MD’s office, beg for a few samples to tide your patient over. Each Patient assistance program has different criteria and some medications have more than one program. Go ahead. Think of a drug and try the website.

US Department of Veterans Affairs Many veterans have benefits they have never accessed. An important court ruling in April of this year has determined that the Veterans Administration must assist Veterans who have had problems getting documents from the VA supporting their claims. If there is a reasonable expectation that documents exist and they are not forthcoming by the VA, the ruling will be in favor of the Veteran.

SAMHSA is an often overlooked resource for field nurses. SAMSHA is the Substance Abuse and Mental Health Services Association; part of the US Department of Health and Human Services. Here you can find resources for all kinds of mental health issues including but not limited to drug addiction and alcoholism. If you suspect but are unsure that there is drug use in the household, make sure the information is left in plain view and encourage the patient to call if for no other reason than to be educated about addiction and how to protect himself or herself in their home.

The Suicide Prevention Hotline is available to all. The Elderly account for 12% of our population but 18% of suicides. Veterans commit suicide at an even higher rate. Each community should have their own hotline so look it up and add it to your list.

Elderly Abuse Resources This site provides both training and education for caregivers so they can recognize elderly abuse as well as a way to search for local agencies who investigate suspected abuse.

For your contributions to the list, consider Meals on Wheels, Community food banks, Churches, and local charities that may assist with home maintenance and repairs. There may be some assistance in your community for help with electric and gas bills. If you are the only person a patient sees on a regular basis, consider calling the local park and recreation center and churches about social activities. Isolation can be deadly to an elderly person especially if they are predisposed to depression. If your patient cannot drive (please tell me they cannot drive), call family members or church members and get them a ride. After a few trips to Senior Belly Dancing in Billings, Montana or the free Tai Chi classes in Little Rock, they might be ready to board a bus going to an unknown location where chocolate and Italian food is served. (Is it just me or does this sound a little like Elderly Abuse?)

If working with others in the community to improve patient outcomes doesn’t fit your current job description, you have two choices. The first is to do it anyway and the second is to continue doing what you are doing right up until your agency is purchased by a larger company or goes out of business. The fact is that your patients need more help than a home health agency can provide or hospital can provide and if they don’t get it, they will end up back in the hospital. That should be enough to motivate clinicians but should you have difficulty convincing the folks who might have to pay for a little training, remind them that when the patients go to the hospital, the referrals go to another agency.

Since everybody seems to be feeling the sting of tighter regulatory scrutiny, there has never been a better time to forge new formal and informal relationships with hospitals in your area. That will be much easier if you and your agency are known as the go to source for getting things done for patients. Questions and suggestions always welcome.

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