A Paradigm Shift for Home Health Care: A New Dream
For years I have dreamed of a day when home health care nurses and therapists would be in charge of their own services, with doctors as integral members of the team – not the “directors” of the plan. It never made sense to me that a physician, who knows little about home health care services, would be required to sign off on our orders. I agree that physicians or nurse practitioners should confirm the working diagnosis and the medications. From that point, it is the professional clinician in home health care that does their assessments, defines the problems in terms of their discipline, and sets the plan of action – not the physician. Having a physician sign our orders and “direct the care” of the home health care makes as much sense as asking the plumber installing the kitchen sink to sign off on, and be in charge of, the electrician, sheet rockers, framers and roofers, and their work. Physicians repeatedly object to the requirement that they sign orders and now, with the new face-to-face documentation, the objections are even stronger.
How did we get here? When – and why – has there been a paradigm where the physician directs the care of other providers? Think of the money spent supporting this false paradigm! Think of all the hours spent by home health care staff gathering a physician signature on the 485. Think of the patients denied services because their physician did not want to deal with the added burden of the paperwork required to obtain the care needed by their patients through the home health agency. Frankly, I do not blame physicians for not wanting the added burden of paperwork that is imposed on them by this requirement.
Therapists are able to establish individual practices that do not require physician oversight. Not so for nurses. Physician control over nursing practice started in the early part of the last century when it was determined that the independent practice of nurses was the single biggest threat to future physician financial growth. (See my article, “Nurse Power: The New Voice in Home Health”). Nurses were considered a financial threat to physician financial futures. As a result, the American Medical Association got Congress to pass legislation requiring that nurses work under the direction of a physician. The current state of affairs is testimony to the success of that effort. Unfortunately, for nurses, consumers, and those who pay, it has not been the best practice.
Many physicians who sign the plans of care developed by nurses and therapists will be the first to tell us that the plans make little sense to them. They sign the plans of care so their patients get the care they need. It’s no surprise the plans make little sense to the physicians. They are not medical plans of care. They are nursing and therapy plans written in the language of each discipline. It is time that home health care plans are recognized for what they are: discipline-specific plans that should be signed by the individual disciplines. Let’s leave the medical components, diagnosis and medication lists to the physicians to sign.
What could the future look like? I dream of a future for home health care where the physician is part of the team and works with the other disciplines to achieve the desired goals identified by our patients. I dream of a future for home health care where each discipline is responsible for their role. I dream of a future for home health care where nursing is responsible for coordinating the overall plan. Just as Medicare recognized long ago, nurses would serve as the coordinator or case manager of patient care in home health care. In that respect, little would change from the current practice.
The physician would confirm the working diagnosis and medications electronically. Each discipline would sign and date their plans. Compliance with the home health care conditions of participation would continue to be the responsibility of the clinical staff at the home health care agency. The requirement that the physician certify the patient as home-bound would virtually disappear.
The focus of the system would change from rule enforcement to that of outcome-focus. With these few changes, costs would decrease and outcomes would improve, as would physician, home health care staff, and patient satisfaction.
A return to individualized plans of care structured in care plan format would help others on the team do better planning. It would help new staff understand the care planning process.
It’s time to dream a new dream for the home health care industry. A dream of true patient-centered care that allows each team member to fully use their particular set of skills and expertise to assist patients in their goal achievement. Time to dream. What are your dreams for the future of home health? Let me know. Together, let’s make those dreams a reality.