Bring home business with home recovery program
Bring home business with home recovery program
Pre-op and post-op visits can help lower LOS
In these days of shrinking home care visits and managed care spreading to Medicare and beyond, how can a home care agency develop a niche that provides more home care business?
The Visiting Nurse Corp. of Colorado in Denver has found an answer to this question by developing programs to provide home care to patients before and after certain surgeries. The nonprofit agency serves 13 counties in central Colorado.
The programs also met the needs of a local hospital that needed to reduce its length of stay for patients receiving hip replacement surgery. And it increased satisfaction among physicians at a sports medical center because the home care visits reduced the calls patients made to them on the late nights following outpatient knee surgeries.
The agency also has developed critical pathways for treating patients who have undergone a lumpectomy or simple mastectomy in an outpatient setting.
"The market is changing, and we have to adapt the way we do business to meet the demands of our partners," says Stephanie Prock, RN, MSN, nurse manager for the company.
"So we’re looking at surgical cases that are not traditionally home care business," she adds.
Prock says the agency’s approach works best in a managed care environment because hospitals and medical clinics will be looking for ways to cut costs without risking patient safety. That’s where a home care agency can step in to help.
The Visiting Nurse Corp. first was approached by a local hospital about providing home care visits to patients who had undergone hip replacement surgery. The hospital needed to cut its lengths of stay to remain competitive in a managed care environment.
"It made us think we need to work more closely with physician groups to encourage them to use our pre-op and post-op programs," Prock says, adding that "the results, which are relatively small numbers, look promising."
For example, the hospital length of stay for patients who had hip replacement surgery declined from a range of seven to nine days before the program began in 1994 to a range of four to five days now, says Beverly Kruse, RN, BS, CRRN, rehabilitation nurse clinician for the home care agency. Kruse says cost outcomes and other details of that program will be published within the next year.
This concept expanded, and now the agency also provides home care services for patients who have had outpatient surgeries, including lumpectomy, mastectomy, and anterior cruciate ligament (knee surgery) repair.
Visiting Nurse Corp. officials have named the new services the Home Recovery Program. The hip replacement visits technically are not part of the program because this surgery still requires a hospital stay. However, both programs are part of the agency’s trend toward helping patients recover safely after surgeries.
"The basic premise of the Home Recovery Program is these are outpatient surgeries that typically would have a 23-hour observation in the hospital," Kruse explains. "Instead, in the program, it’s purely outpatient surgery, where they have surgery before 2 p.m. and they go home on the same day."
A home care nurse will visit the patient on the evening after the surgery and then again the following morning.
The programs have three major features:
1. Nurses and therapists assess safety.
"We look for the patient to be safe in the home after surgery and identify any unusual psychosocial situations or unsafe or inappropriate living conditions," Kruse explains.
An example might be if the patient is a primary caregiver for someone who is more frail than the patient.
"Maybe the husband has been caring for an invalid wife, and then after he has hip surgery, he’s gotten too frail to transfer her," Kruse says. "That means she needs someone to care for her while he recuperates, so we look for some other family member to help out."
The agency provides detailed goals about what will be accomplished on these pre-surgery assessment visits. These have been used to convince payers that the visits were medically necessary.
"Some HMOs continue to deny pre-op visits as being duplication, but we’ve been successful in convincing insurance companies that even one pre-op visit is helpful," Kruse says. "Ideally, we’d like one pre-op visit for the nurse, one for the physical therapist, and one for the occupational therapist. But if we only are approved for one visit, we’ll send the physical therapist out there to do a global assessment."
The postoperative home assessments have a similar focus.
Kruse wrote a critical pathway for post-surgery visits to patients who had knee surgery (anterior cruciate ligament) repair in an outpatient setting.
The assessment guidelines for two visits after the knee surgery included the following:
• home safety;
• pain management;
• bleeding, drainage from incision;
• medication compliance;
• nausea;
• coping;
• compliance with equipment;
• incision condition;
• compliance with ice, splint, crutch;
• continuous passive motion;
• learning and practice of instructions;
• observance of safety rules.
2. Nurses and physical therapists teach patients.
Instruction is crucial to patients’ rapid recovery from surgery, particularly in the case of younger patients who may want to return to work as soon as possible, Kruse says.
Knee surgery patients, for instance, are given detailed instructions on how to rearrange their homes and what knee-extension exercises to do. They’re also taught how to control pain; how to use ice, crutches, and splints; what signs and symptoms to report to the physician; how to use medications; what risks to avoid; and how to solve problems.
"If they practice what they’re taught, then they may recover in a reasonable amount of time," Kruse says.
Patients also are taught when to eat solid foods and fluids, what kinds of side effects they might have from their medications, and when they should contact the physician to report a high fever or complications.
"We help them out with a medication schedule, and we explain to them how to decide when to take their medicine," Kruse adds.
3. Therapists and nurses provide follow-up care.
Nurses make sure patients are complying with medication regimens and check blood work to see whether doses need to be adjusted.
Nurses also monitor the patients’ incisions to see whether there are any healing problems, and they change dressings and clean wounds.
Physical therapists work with the patients after hip replacement surgery and knee surgery to help them gain mobility faster.
Kruse says the post-surgery visits typically approved for hip replacement surgery are a total of seven visits by the physical therapist and about five visits by the nurse.
For the other surgeries, the postoperative visits usually are limited to two nursing visits.
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