The referral process in the home health world deals mostly with what happens with the physical ailment. However, the mental health of your patients will affect the ability for your agency to achieve desired home health outcomes. Agencies have to deal with the “grade card” that comes in the form of STAR ratings. So, let’s look at how to make sure the patient is taken care of physically as well as mentally.
In this industry, it would not be unusual to receive a referral like this:
- 76 year old male
- Post-op CABG x 4
- History of : Diabetes Type 2, arteriosclerosis, obesity, smoking, increased cholesterol and hypertension
We are trained to focus on the most pressing issue for the patient. In this case, it is of course the post-op care from open heart surgery. Nurses will methodically assess cardiac, respiratory, and circulatory status while teaching self-care and diet changes. If therapy is involved, the therapist is getting the patient to a routine exercise program advancing to cardiac goals appropriate to those after heart surgery. You have the patient for the next month during the recuperation phase. Now, the patient is not homebound and ready for discharge. But, wait…..
Prior to the discharge, we know this has been a life-altering experience that has gotten him on a path to smoking cessation. He is notably irritable related to avoiding cigarettes. He has lived with the diabetes diagnosis for the last 5 years and has had to monitor blood sugars and diet. Now, he feels even more frustrated with more limitations to what is he “allowed” to do now. He is very frustrated that he has not been medically cleared to drive yet. Although he has never been diagnosed with any type of mental health issues, the acute signs of anxiety, sadness, fear and frustration can be right in front of clinical staff and not addressed. Care planning today doesn’t often address the things that are routine for the clinician, but not for the patient.
How Do We Change Care Planning?
This is a good goal for CQI. Maybe it lies in initiatives that address specific mental health issues as part of the routine assessment. Do you provide adequate screenings for anxiety and depression? That doesn’t mean is there an assessment done. It means, does that assessment meet what your clinicians need to adequately care plan addressing mental health concerns. Does the patient acknowledge these issues during assessment? Are these issues then addressed in the care plan? If agencies do not address the routine stresses associated with patient illness, the ability for the patient to be proactive in his or her care becomes moot. Getting back to the basics in care planning will be key to working through this world of PDGM. Changing your care planning process and clinician buy-in takes time and education. If you really want improvement in STAR ratings, this care planning can not just be about the physical.
Let Us Help With Your Home Health Outcomes:
At Kenyon Homecare Consulting, we focus on high-quality, patient-centered care focused on outcomes that are both clinically and fiscally positive. We can provide the educational teaching and help with operational changes to make every visit and every care plan most effective. Call us at 206-721-5091 or contact us online to see how we can help your meet your outcome goals.