Appropriateness for home care services
By Elizabeth Hogue, attorney
The private duty home care industry is appropriately focused on "the bottom line" — i.e., operating a profitable business. In order to help ensure profitability, agencies must make certain that patients are not admitted who are not generally appropriate for home care services. Patients who are admitted for home care who are not generally appropriate for such services gobble up the agency’s resources with an ultimate adverse effect on the bottom line. In addition, admission and continuation of services to patients who are inappropriate for home care enhances the likelihood of legal liability in this litigious society.
Consequently, private duty home care agencies must evaluate every patient for general appropriateness for home care before they are admitted and for general appropriateness for home care after they are admitted. Patients who fail to meet even one of these criteria prior to admission should not be admitted, services should be discontinued to patients who met these criteria upon admission, but later do not meet them any longer:
• The patient’s clinical needs can be met at home.
• The patient can either self-care, or there is a paid or voluntary reliable primary caregiver to meet the needs of patients when staffing cannot be provided or between home visits.
• The patient’s home environment supports home care services.
The ability of home care providers to care for medically complex patients has been greatly enhanced in recent years. Consequently, it is relatively rare that the clinical needs of patients cannot be met at home. These rare instances may involve, for example, patients who are prematurely discharged from an institutional setting.
In addition, patients must be able to self-care, or there must be a paid or voluntary reliable primary caregiver prepared to meet the needs of patients when home care staff members are not present. Private duty home care providers may encounter very significant difficulties with these criteria as follows:
• When staff evaluate patients for admission, they will certainly identify a primary caregiver. But, realistically speaking, about all they can tell about primary caregivers upon admission is that they are vertical and breathing. The competence and reliability of primary caregivers can only be assessed over time.
• Staff members are often also working uphill against the expectations of patients and their families. Specifically, discharge planners in institutional settings are under so much pressure to move patients out of the institution that they rarely explain to patients and their families what their role in home care must be. Consequently, patients often are referred to home care with the expectation that nurses will take care of everything, just as they did in the institution. This expectation is further enhanced by the general lack of understanding by many patients and their families about home care. In addition, in the face of illness, it is only human for vulnerable patients and families to want agencies to simply step in and take care of everything.
• In addition, some of the tasks that primary caregivers may be expected to perform are repugnant to them. The "big three" tasks are wound care, changing diapers, and giving injections. When these tasks are involved, the reliability of primary caregivers may be sorely tested.
What staff can do to improve the odds
What can agency staff members do to increase the likelihood that they can identify and support primary caregivers in ways that will enhance the likelihood of reliability?
During the admission visit, staff should be very direct with primary caregivers about the role they must play. They must further make it clear that if primary caregivers fail to fulfill their role, patients simply cannot remain in home care. For example, staff may say to potential primary caregivers: "In order for the patient to be admitted to home care, you must be willing to dress the patient’s wound twice a day, change the patient’s diaper many times each day, and inject the patient three times each day. Are you willing to perform these functions?" In addition, the staff should be very direct about the fact that the agency will use reasonable efforts to provide staffing, but cannot guarantee it. In instances when the agency cannot provide staffing, the primary caregiver must be prepared to care for the patient’s needs based on education and teaching previously provided by the staff. This very direct discussion and the potential caregiver’s agreement or refusal to perform these tasks must be documented.
If it appears that there is a reliable caregiver and the patient is admitted, staff must continue to monitor for reliability. Staff must specifically document every instance of noncompliance by primary caregivers. It is not sufficient to document that the caregiver is non-compliant. Rather, staff must indicate that they changed the patient’s diaper at 2 p.m. and place a red mark on the tab at 2 p.m. When staff returned the next day, the patient was lying in excrement and urine and still wore the labeled diaper. Then staff must re-teach primary caregivers, and if appropriate, get a return demonstration which, of course, must be documented. This process should encourage reliability by caregivers.
Finally, the patient’s home environment must support home care services. Documentation related to this issue is often provided in the form of safety in the patient’s home. This term is very vague and can mean everything from too many scatter rugs on the floor to rats gnawing on intravenous tubing. So staff members should be careful to document that the patient’s home environment will not support home care services for specific reasons.
(To obtain additional information about the risk of legal liability discussed above included in a book, Legal Liability, send $25.00 including shipping and handling to Elizabeth E. Hogue, Esq., 15118 Liberty Grove, Burtonsville, MD 20866. To obtain a complete set of policies and procedures related to termination of services when patients are no longer appropriate, send $105.00 to the above address.)