If I asked your agency the question in the title to this article, what would the answer be? The reality is that once PDGM came and therapy thresholds disappeared, a hard look at care planning was going to be needed by a whole lot of agencies. Now, the question is whether the care is the same but with a whole lot less therapy or whether your care planning equates to better patient care. Or, maybe the answer is neither?
Patient Scenario Then Versus Now:
Let’s consider a patient in his 90’s who is post hip replacement returning to his 2-story home. He lives by himself as he is a widower, but he had previously been independent and still drove and worked. His meds have historically been delivered in blister packs which made things easier for him. There were changes made at the hospital and now he has 2 medications in blister packs that he is no longer to take. He does not know which pills those are as the blister packs have them all together. Because he would initially need someone with him, he decided to pay for someone to be with him 24 hours a day upon his arrival home until he was able to stay alone. His paid daytime caregiver was a nurse who stayed until 7-8pm every night before the night caregiver arrived. So, let’s take a look at what this care plan would have potentially looked like in 2019:
Nurse comes out the day after hospital discharge and admits on Saturday. Therapy comes out Monday. Patient is told he will have an aide come out and he will be contacted Monday about a schedule. The nurse who is paid for by the patient begins on Sunday. Agency does not know if this nurse was given copies of any paperwork from the hospital regarding the patient’s care. This may look like a very typical care plan for the patient:
SN 1 wk1, 2 wk1, 1 wk 2; PT 3 wk 4 beginning week 2; HHA 2 wk 4 beginning week 2
In this scenario, we still have everything that happened in the paragraph above. However, the frequencies look like this:
SN 1 wk 1, 1 wk 2; PT 1 wk1 beginning week 2, 2wk1, 1 wk 1 (for the PT to DC); No HHA. Discharge within 30 days. The patient never heard from anyone on Monday or thereafter about getting a home health aide.
Here’s The Problem:
Does the problem really lie within the number of visits here? Well, not necessarily. In this case, it absolutely was a problem. Here’s the thing though, it doesn’t have to be. Let me explain. This patient was lucky enough to be able to pay out-of-pocket for care by the nurse during the day. So, she was able to assist with personal care needs and make sure to have him walking at appropriate intervals to promote therapy goals. She was able to manage the issues with his meds in the blister packs and help facilitate his medical needs. However, at no time was the paid nurse given instruction by the home health agency regarding care. She was not included as his caregiver in care planning. There was no schedule of visits provided so the nurse and patient had no idea when staff was planning to come. Therefore, they didn’t really understand the care plan for the patient. In the case of this patient, the disciplines did their individual things and didn’t effectively communicate with the patient or paid caregiver. In addition, when the patient was discharged to outpatient, the home health agency did not communicate with the physician to get the order to transition to outpatient. Instead, the paid nurse at the home was told it was her responsibility and that the home health agency doesn’t do that.
Now, this scenario I described above is poor and unfortunately, it is not unique. At Kenyon Homecare Consulting, we have long been focusing on unified care planning processes to get agencies ready with fully integrated care plans for the start of PDGM. However, what we have described above is the problem with a non-integrated care plan once therapy thresholds disappeared. The problem doesn’t lie in the fact the number of therapy visits decreased, it lies in the fact that each visit didn’t do everything they could do while present in the home. The paid help was the one who followed up with the doctor about the meds in the blister packs. The agency nurses did not complete anything on a rehabilitation level when present and therapy did not help with meds as appropriate within scope of practice. Also, since when does home health not facilitate discharge planning to include getting the order for outpatient?
How Could This Care Plan Have Worked?
Well, the nurse who admitted could have had communication with the paid caregiver and followed up with the MD about the medications that remained in the blister packs. The patient was not told which meds in the blister pack he should not take. The paid nurse remedied this the next day. If an aide was provided, the therapist could and should have given specific interventions for the aide to complete with the patient as delegated within the aide scope of practice. The nurse could have also completed rehabilitation interventions when present in the home. If we put the home health aide in a couple times a week for 2 weeks, this means the patient would have had rehabilitation intervention a total of 10 times within that month of care as opposed to 3. In addition, had the paid caregiver been included as an integral part of the care plan, she could have played an even bigger role for patient care and advancement of the care plan. Here’s the worrisome part, what if the patient didn’t pay for out-of-pocket care? Would he have slipped through the cracks here? Would he have ended up back in the hospital? Maybe a home health aide would have been sent? But, would the disjointed level of care still be provided even if he had more visits?
These are the problems patients will continue to face without integrated care planning. Agencies are trying to comply with patient needs while remaining financially viable. This is definitely not a new concept for our industry. However, we need to have fully integrated care planning that includes well planned visit goals each time and for each discipline. Everyone needs to function within maximum scope of practice and caregivers need to be a part of patient centered care. This way, it is not necessary for the patient to have 12 visits from the physical therapist, but rehab goals are addressed with every discipline.
Care planning includes weekly communication so everyone has a game plan before they ever hit the patient’s door that week. And most importantly, the weekly communication about the intended care goes to the patient and caregiver so they know exactly what is going to happen and its intended outcome. If you want help to put this into motion within your agency, it takes planning and intention behind your care plans. Call us at 206-721-5091 or contact us online if you want help to make this care a reality.