Prepare for patient ‘goodbyes’ from day one

Arkansas, which has very little managed care pressure, might seem like an unlikely place to find a home care agency that is working hard to reduce visits through early discharge planning.

Arkansas is one of only nine states in which HMO penetration, at 8.3%, has not yet hit double digits, according to a 1997 report by Hoechst Marion Roussel in Kansas City, MO.1

Yet, Drew Memorial Hospital Home Health Agency in Monticello, AR, is acting as though managed care has already arrived. The agency began early last year to shift its philosophy to one of cutting visits and costs.

"With this ever-changing industry, everything is turning around completely from home health as we knew it years ago," says Karon Beavers, RN, director of home health for the county-owned, nonprofit, hospital-based agency that serves seven counties in southeast Arkansas.

"As a director, I’m looking at trying to decrease visits per patient," Beavers adds.

The agency, which has a patient mix that includes some post-surgery patients and some patients with chronic illnesses, has succeeded so far. The average length of stay in home care for all patients from December 1996 to May 1997 was 44 days. This compares with the six months between June 1997 and November 1997, in which the average length of stay had dropped to 29 days.

Beavers says the reduction in length of stay resulted from a combination of early discharge planning, a new discharge form, earlier and more intense patient education, and a focus on educating nurses about why the agency will need to provide quality care in fewer visits.

"We emphasized to nurses that we could not keep patients just because they wanted us, and we educated nurses about the changing trends of Medicare," Beavers says. "The discharge planning sheet is just a tool to help us get where we want to go."

The reduction has been tough on the agency’s revenues, Beavers says. "Certainly we’ve seen a little decline in our revenues, but it hasn’t affected the amount of reimbursement per visit," she adds.

The change will allow the agency to increase its volume, but Beavers says she doesn’t anticipate the number of Medicare patients to rise. Rather, any increase will come from patients who have commercial insurance, and that trend is already beginning.

"We’ve seen an increase in commercial insurance business," Beavers notes. Before the agency started early discharge planning, its patient mix was 95% to 97% Medicare patients, with Medicaid and commercial insurance making up the remainder. That has changed so that now only 90% of the agency’s patients have Medicare, and Beavers says she expects that percentage to drop in the future.

"We hope to survive this transition period," Beavers says, adding that the new emphasis on discharge planning will enable the agency to survive the coming Medicare changes.

Patients can visualize end of care

Drew Memorial Hospital Home Health Agency created a brief discharge planning sheet for nurses to read to patients on the first visit and to have them sign. The simple form makes it clear when and why a patient will be discharged.

"Patients just thought they would never be discharged, so we started to get that concept in their minds that they’re not going to be in home care forever," says Lela Wilson, RN, quality assurance coordinator for the agency.

Beavers says this is a departure from the agency’s traditional practice. "In the past we waited until a patient was more stable before we started discharge planning," Beavers says.

Nurses explain to patients why they need them to review and sign the discharge-planning form, and they explain Medicare’s criteria for reimbursement of home care services.

This new philosophy also has prompted the agency to start patient teaching during a patient’s initial visit. The education includes all aspects of the patient’s care, such as medication use and the disease process.

During the initial assessment, the nurse fills out a 19-page admission form that incorporates data from the Outcomes and Assessment Infor mation Set (OASIS). Before the agency used OASIS data, the form was five pages. The admitting nurse obtains the patient’s history, examines the patient, documents the patient’s medicines and problems, goes over the patient’s rights, and then asks the patient to sign the discharge form.

When the program first started, nurses often forgot to ask patients to sign the discharge form. So the agency changed its process to assign one nurse to be the admission nurse for a given week. This nurse admits all patients, which has made the process more consistent, Beavers says.

At times when this nurse is not available, other admission nurses are given an admission packet that includes the discharge form. Since these changes were made, there has been less trouble with nurses forgetting to talk with patients about discharge planning, Beavers adds.

The discharge form lists in large print: "Drew Memorial Hospital Home Health Discharge Planning Sheet." It has space for writing a patient’s name, doctor’s name, date of admission, the projected discharge date, patient signature and date, and nurse’s signature and date.

Then it reads: "You will be discharged from DMHHHA if services are paid by Medicare and:

A) you are no longer homebound or;

B) skilled services are no longer medically necessary or;

C) you are no longer under the care of a physician.

If you have another pay source:

A) goals are met and services no longer needed or;

B) physician discharges you."

Patient satisfaction has not changed at all since the agency started its early discharge planning, Wilson says. "We send out a patient questionnaire to everyone we discharge, asking them about their services, and I have not had one bad mark on one of them."

Prepared patients are more receptive

Patients now are more receptive to being discharged than they were in the past because it no longer seems like such a surprise, she says. "Before, we’d say, ‘We don’t have any reason to be here so we’re going to discharge you now,’ and that was too abrupt."

Wilson says sometimes a patient will refuse to be discharged and will contact the physician to say he or she is not ready yet.

If this happens, Beavers says, and "they become ineligible for the Medicare benefit, we often try to switch them to a personal care program through Medicaid or self-pay."

If that doesn’t work, the agency has charity care available that still is subject to physicians’ orders.

Nurses now write patient goals at the very beginning of care and then adjust and document them during each visit, Wilson adds. The goals are listed on the patient’s chart under utilization review of discharge planning.

An example of a goal for a congestive heart failure patient might be that the patient would not have an acute episode within the next nine weeks. Or a wound patient’s goal might be that the wound is healed within three weeks.

"The admission nurse will establish all the goals within the first day or two," Wilson says.

[For more information, contact: Karon Beavers, RN, Director of Home Health; Lela Wilson, RN, Quality Assurance Coordinator, Drew Memorial Hospital Home Health Agency, 778 Scogin Drive, Monticello, AR 71655. Telephone: (870) 460-3585.]


1. Hoechst Marion Roussel, HLS Management Systems, The Business Word Inc., SMG Marketing Group Inc. Managed Care Digest Series 1997. HMO-PPO/Medicare-Medicaid Digest; p. 20.