CM provides complex medical management

Working on a private-pay basis

When Jan T. Homan, RN, BSN, was a home health nurse, she encountered several "revolving door" patients who would receive home health services for six weeks, keep their chronic condition under control for a few months, then end up back in the hospital and be discharged again with home health services.

"I knew that there was a way to manage the care of these patients better. Medicare pays for home health services for a limited time. I decided to try something different, where clients tell me how often they want me to visit and for how long in order to have a better quality of life," says Homan, who started Lakeview Nurse Associates, a Milwaukee, WI, independent chronic disease management firm, 10 years ago. (For details on how Homan started her firm, see related article, below.)

Most of Homan's referrals come from geriatric care managers who provide care coordination for seniors on a private-pay basis and refer patients who need complex medical care management. "Sometimes, people call me about their children or a neighbor. I received a referral from the housekeeper of an elderly woman who was given my name by the housekeeper of another client I visited until she passed away," she says.

Homan sees most of her patients weekly in their homes, coordinates with their physicians, and often accompanies them to their physician visits. She conducts a thorough assessment every time she visits a patient's home, depending on the patient's disease and risks. For instance, with diabetics, she checks the blood sugar log and examines the patient's feet. With heart failure patients, she checks for edema and changes in weight. "The goal is to catch problems early and work with the physician over the telephone to take steps to keep them out of the emergency department and the hospital," she says.

With the permission of the client, Homan sends notes from her visits to the out-of-town family members to keep them informed. "I have found that it is important to communicate with family members, especially those who live out of town. When children come to visit their parents a few times a year, they don't really know what is happening day-to-day. If I keep them informed, they aren't blindsided when their loved one can no longer live independently at home," she says.

Most of her patients are being treated by multiple specialty physicians, who often aren't aware of what other specialists have prescribed and recommended. Homan keeps them in the loop and updates them on the patient's current medications and treatment plans. When her patients are hospitalized, Homan contacts the hospitalists to help them understand what was happening with the patient in the community.

When patients don't think it's necessary for Homan to go with them to their doctor visits, she coaches them on questions to ask the doctor and symptoms to report. She faxes a one-page update on what has been happening with the patient, such as their blood pressure ranges, a list of medications, and any issues she would like the doctor to address. There is a space at the bottom of the sheet where the doctor can update Homan on the visit. "Many times I receive phone calls from doctors who are sitting in the exam room with their patients and have very specific questions about what is going on at home," she says.

Recognizing that many of her patients have short-term memory problems, Homan creates a folder of information that she leaves in the patients' homes in an easy-to-find place such as the kitchen table. The folder includes the current medication list, instructions from the physicians, and goals for the patient. For instance, a client's physician had suggested that she take her iron pills with orange juice to improve absorption. She forgot to do this until Homan visited the next week and added those instructions to the folder.

She goes through the refrigerators and pantries of patients who have dietary restrictions and make suggestions about what they should eat and what they should throw out. In some instances, she puts post-it notes on the items they need to limit. For instance, one patient is diabetic and had problems understanding what he could and couldn't eat. She put notes on his favorite cereal instructing him to eat it only once a week. "I didn't want him to have to give up the things he likes. I just wanted to make sure he eats them only occasionally," she says.


Do the homework before going on your own

Before Jan T. Homan, RN, BSN, started Lakeview Nurse Associates, an independent chronic disease management company in Milwaukee, WI, she contacted the Wisconsin Nurses Association to find out what tasks she could do in her business and still work within the scope of practices for nurses in her state.

An attorney for the nurses association advised her to follow the same rules for home care. "I don't administer medication without a doctor's order unless it's over-the-counter and not contraindicated for the patient's condition and other medications," Homan says. "I don't do wound care without a doctor's orders. However, I don't have to get a doctor's order for the other services I provide because it's the client, and not Medicare or an insurance company, that is paying me."

She advises case managers who want to start a similar business to make sure their services fit into the state's scope of practice for nurses. Every state has different regulations, she points out.

Homan began her nursing career as a RN in the emergency department in 1978, then she worked as a nurse case manager in Medicare-based home care agencies for 20 years. "I left nursing for a year because of a back injury, but realized how much I missed it," she says. "I didn't want to go to a traditional home care agency so I decided to try it on my own."

When Homan started her business, she sent a one-page letter of introduction "to every person I knew" telling them about the services she could provide. She also contacted the Medicare-based home care agencies which refer patients who don't meet the Medicare criteria for home health services. The referrals started to trickle in, many of them by word-of-mouth. Homan tracks the referrals to determine marketing opportunities.

If she determines that a patient meets Medicare criteria for payment of home care, she refers them to a different agency. "I don't want people to be paying out of their pockets for services that Medicare will provide," she says.

Homan typically visits her clients once a week and charges on a per-visit basis. The fee covers transportation, telephone calls in between visits, and paperwork. She's also on call 24 hours a day for her patients. If the patient calls after hours or on weekends, Homan charges for the phone call and time and one-half if she has to visit after hours. "Most of the after-hours calls can be handled over the telephone," she says.