For years I have dreamed of a day when home health nurses and therapists would be in charge of their own services and doctors would be part of the team but not the “directors” of the plan. It has never made sense to me that a physician who knows little about home health services would be required to sign off on our orders. I agree that the physicians or nurse practitioners should confirm the working diagnosis and the medications, but from there on it is the professional clinician in home health 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 period makes as much sense as asking the plumbers building a house to sign off on and be in charge of the electrician, the sheet rockers, the framers and the roofer’s work. Physicians have repeatedly objected to the requirement that they sign orders and now with face to face documentation, the objections are even more stringent.
So how did we get here? When and why has there been a paradigm that the physician directs the care of other providers? Certainly the therapists have been able to have individual practices that do not require a physician oversight, but not nurses. The origins of 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. Nurses were considered a financial threat to the physician financial futures. As a result, the American Medical Association set out to get 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 plan. Unfortunately for nurses, consumers and those who pay, it has not always been the best practice.
Many physicians who sign the plans of care developed by the nurses and therapists will be the first to tell us that the plans make little sense to them but they sign them so their patients can get the care they need. Is it any wonder the plans make no sense to them? 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 plans are recognized for what they are, discipline specific plans that should be signed by the individual disciplines. The physician s needs to continue to sign the medical components, diagnosis and medications lists, but the rest belongs to the individual disciplines.
Think of the money that is spent trying to support this false paradigm. Think of all the hours and time spent by home health staff gathering a physician signature on the 485. Think of the patients who were denied services because their physician did not want to be deal with the added burden of the paperwork required to gain their patients the care 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.
So what could the future look like? I dream of a future for home health where the physician is part of the team and works with the other disciplines to achieve the desired
goals that our patients have identified. Each discipline is responsible for their part and nursing is responsible for coordinating the overall plan. Medicare recognized long ago that nurses should be the coordinator or case manager of patient care in home health. In that respect there would be no change to the current practice.
The physician would confirm the working diagnosis and medications electronically and each discipline would sign and date their plans. Compliance with the home health conditions of participation would continue to be the responsibility of the clinical staff at the agency and the requirement that the physician certify the patient is home bound should go away.
If the intent of the physician certifying the patient is homebound was intended to prevent fraud, it is evident that it has not been successful and should be dropped. The best person to determine homebound status is the clinician in the home doing the assessment. However there is another serious issue with the homebound rule. It interferes with the home health staff’s ability to provide the care needed to really return an individual to full capacity and independence. Much of what home health does is to assist the patient make life style changes in order to stabilize their condition and prevent further exacerbations and the subsequent need for more expensive sites of care. To achieve these goals, particularly for those with chronic diseases and co-morbidities time is needed beyond a 60 day episode. But, because of the homebound requirement, home health barely gets the patient to begin the changes to their life and they are discharged because they can no leave their homes. Experience provides evidence that it may take as long as 6 months to successfully integrate a change in lifestyle. There seems to be a beginning glimmer of hope with CMS beginning to recognize that particularly those with chronic diseases need longer times of care and support beyond the current homebound phase.
The focus of the system would change from rules enforcement to one of outcomes focused. What is the patient achieving in terms of their desired goals and outcomes and then what are the costs. I believe that with these few changes, cost would decrease and outcomes would improve as well as physician, home health staff and patient satisfaction.
Finally the 485 needs to be revised and made to reflect these new changes. I have had numerous physicians complain over the years that the 485 makes no sense to them and provides them with little useful information other than the diagnosis and the medications. Physicians are asking for information about their patient’s progress and responses to services as well as any identified medical issues that they would need to tend to. That is not an unreasonable request and as a member of the team something we would want to provide them. This will require a paradigm shift for home health clinicians however.
I believe a return to individualized plans of care that are structured in care plan format would not only help others on the team do better planning, it would help new staff new to the home health practice understand the care planning process. The current system does not support critical thinking of the clinical staff and the whole process has become an exercise in checking items in a list.
It’s time to dream a new dream. These are just a few of the things I see as needed for the home health industry to achieve the goals of true patient centered care that allows each team member to fully use their particular set of skills and expertise to assist the patients in their goal achievement. Time to dream. What are your dreams for the future of home health? Let me know. Together we make a difference.