As a medical professional, I was always interested in, and usually shocked and saddened by the conditions of a person each time I visited a new patient as a homehealth nurse.
My choice to work with Medicaid and Medicare patients was solely because they are, for the most part, the forgotten and most destitute of patients. Many were the reasons for the depth of hopelessness and despair evident in the faces and home environment of my patients.
The task of assessing previous diagnoses and intervening to find newer ones and then beginning the process of teaching on those diagnoses was not a strain, but rather a real privilege.
The heartbreak and the difficulty in the care was in watching the majority of these patients, whose primary morbid diagnosis was longstanding, at least 10 years, not follow through on their careplan and instructions.
Unfortunately, one of the biggest barriers I experienced as the patient’s advocate (the number one job of a nurse) was disassembling the attitudes and perceptions the patient’s own medical providers had towards and of the patient.
Many, many physicians and colleagues would give me reports of “combative and noncompliant” statuses for these patients, citing that they “just don’t take their medicine” or “they won’t keep their doctor’s appointments.”
Each report made me think differently of the messenger as my experience in many medical environments taught me early on that no one wants to be or stay sick, but that there are always an excess of conflicts and obstacles to the patient obtaining the necessities required for them to actually follow instructions or make it to their appointments and seemingly, those important factors had neither been addressed, investigated or considered by the prescribers and providers.
There have been and still are just a handful of medical providers who recognize this reality and attempt to bring some resolution to it by requiring their nursing staff, as should be, to assist the patient in acquiring necessities, such as medical transportation covered by their insurance, or assistance in finding prescription programs to cover medicine copays.
Just those needs met go a huge distance in increasing compliance of care instructions and appointment keeping. I have worked for several homehealth companies whose own creed to its patients was to liason for them in this manner and those were the most fulfilling positions I had.
This article is to address the patient and family/caretakers to inform them of the best ways to find and utilize resources and to inform other medical providers of the reality of the reasons behind much of the “noncompliance” that is seen.
Homehealth originated as a means to end repetitive emergency room visits and “unnecessary” multiple office visits. It soon became a tool for the medical community to better monitor higher risk patients’ daily compliance and decisions in diet, medication management, new onset of disease and progression or reversal of co-morbidities (secondary diagnoses that complicate the primary diagnosis) among other issues.
It is a fantastic idea if implemented with honest intentions void of the notion to use this vulnerable population to glean as much as possible from Medicaid and Medicare without providing the excellent care documented as performed.
In other words, look out for the cheaters when searching for a homehealth company or in assessing the one a patient may already have.
They are everywhere and hard to discern often because of extravagant agency offices seeming to elicit false confidence in a “successful” company or smooth talking Case Managers who promise the world and deliver absolutely nothing.
The situation I walked into most times than not was having to hear from the patients how their prior nurse had visited once that month yet they were supposed to have been seen once or twice a week. When investigated it was documented (and meticulously, I might add) that there had been several visits that month that had already been billed to the insurance.
This dishonesty and unethical behavior left the patient without their medication refills and so, each one was on the brink of an ER visit…the very situation that homehealth is there to prevent.
Much of the time I had to send them to the ER for very high blood pressure, wounds that had not been treated or dressed and were now very infected or the patient had suffered a heart attack at home and not gone to the ER and could not get a hold of their homehealth nurse to report the incident.
These are real and frequent incidents. I had one physician whom I called to report my patient having had 2 strokes between doctor’s visits, tell me to send this patient, (who was currently having stroke signs and symptoms) to his office, not the ER, because “My patients don’t go to the ER. They go through me. first.”
I’m sorry, but that is medical negligence. This particular patient had sat in the doctor’s office twice in the previous months during a stroke each time and was now blind due to those incidents. Even after this physician saw the patient on those days, he declined for her to go to the ER for care and sent her home with a higher dose of medication for her blood pressure.
This patient was not too interested in taking her medication as she didn’t trust her provider. After reporting the incidences and the situation to my own supervisor, I assisted her in finding another medical provider. And, yes, I sent her to the ER.
Miscommunication or lack of communication regarding the patient’s need for proper resources would result in the patient’s distrust in the homehealth company and the medical providers involved to meet their needs. This perpetuated most “noncompliance.”
To better advocate for yourself or someone else, refer to the following decisive methods a little further down the page for identifying an effectual homehealth company vs an ineffectual homehealth company and how to receive the best care from that company and your homehealth nurse.
Homehealth is a business, so it stands to reason that there should be flexibility allowed in both expectations for the homehealth company and for the patient’s compliance.
Interpreted, as an example, that means scheduling home visits are based on the length of time of the previous home visit a nurse has and the next patient can expect to see their nurse within an hour timeframe of the visit time (ie: the nurse should communicate that she will be there between say, 1:30 and 2:30, giving the nurse time to complete the previous visit, account for its possible emergencies or other needs and the time to travel to the next patient).
It is also as a clarification that the homehealth nurse should take into consideration that a patient whom has not had homehealth at all or any positive previous homehealth experience, may be slower to respond to instructions and compliance based instructions (medication regimen as an example).
Secondly, to determine if the care you are receiving is deserving of your insurance dollars and time, ask these 7 questions:
- From the time your MD ordered homehealth, how long did it take to receive a call from a homehealth company? (Ideally, the patient would want to investigate local homehealth agencies in the area and choose one for the MD to fax the order to, but not all patients have this capability or any assistance to do so.)
Two weeks is a normal timeframe. Past that, call your MD and ask which company was faxed the order, call that company, or have the office nurse do this, and inquire as to any holdups. Sometimes, insurance is the holdup. Other times, the chosen homehealth agency did not receive the order, lost the order, or was so disorganized that they themselves don’t know why they hadn’t called you.
2. When you do receive the initial call from a Case Manager to schedule your admission to homehealth, are they respectful of your time and schedule? If they communicate to you that they “only have this date and time available” to interview for the admission (not all patients ordered homehealth will be admitted to any homehealth agency), be very wary. As nurses, we are being invited into your home for the privilege of offering our services to you. You are not at our mercy. Your time and schedule should be considered for each appointment an agency makes to visit you.
3. When a nurse comes to your home, are they respectful of your home environment? We need to know if you have animals or annoying/intrusive family members that would complicate a visit, but we certainly do not pass judgement regarding those or any other issues/situations in the home..barring criminal acts including drug use or abuse of the patient, which would have to be reported and reconciled through proper law and state enforcements.
4. Was your initial admission assessment thorough? This can last up to 2 hours. Use this guideline:
a) Full medical, social and environmental (complete list of diagnoses and medical issues, family history and current status and issues, risks to your safety in the home) assessment taken?
b) Full assessment /inquiry as to any and all needs you may have?
c) Complete physical assessment performed including all body systems check, vital signs, blood sugar checked?
d) All your questions answered to your satisfaction?
e) Explanation of the process of homehealth visits, documenting in the home (tablet or laptop usually) and how and when to reach either your nurse or the agency or the ER for health issues or questions you may have? You should be provided with a working number that is answered by a nurse or knowledgeable agency staff at all times.
5. Have all of your medications been documented and all have recent refills and correct counts per the nurse? This is imperative to effectively managing your health and improving its status. This must be addressed and handled at EVERY homehealth visit.
6. After discussing your careplan (which includes the frequency of your visits, the diagnoses nursing will address and interventions, teaching and nursing tasks to be provided) do you understand it and agree to it?
7. Has an Emergency Plan been created and discussed with you? This includes exact instructions for the patient and family for handling weather emergencies, local and national disasters and personal health crises.
In addition to the above, as a patient or family member of the home health patient, make sure that changes in health or problems with any delivery of care (such as not receiving ordered medical equipment) are reported to the homehealth nurse preferably at the time of occurrence but certainly at each visit.
Medication refills are to be called in per the nurse and the patient, as a combination strategy, but ensure that refills are in the home prior to a home visit so that the nurse can properly dispense medication in a medbox, if ordered.
Reporting the names of new doctors and any scheduled healthcare visits are imperative at each nurse visit as a homehealth visit usually includes calls to the PCP or to a specialist.
In revisiting the original reason for homehealth, remember that the patient is to be properly and successfully cared for and should expect an outcome of improved health. If that necessary benefit is absent from your homehealth care, determine your part in that, if any, and take action to change either your assigned nurse or change the healthcare company immediately.
Yes, your life actually does depend on it.