The primary role of the home health provider is to teach the patient/caregiver how to manage her/his own medical and functional needs. A successful discharge means the patient/caregiver is able to recall and/or demonstrate all the preventive care needed to maintain medical and functional stability.
Risk factors often exacerbate medical conditions leading to an ER visit and/or hospitalization. A patient's vision deficit increases the likelihood of falls, social isolation negatively affects recovery, transportation problems prevent the patient from making necessary medical appointments.
A successful discharge is also mandated by Medicare. The Home Health Value-based Purchasing tracks how frequently home health patients visit an ER or is hospitalized and includes financial penalties for excessive hospital admissions within 30 days of hospital discharge.
Important Question Number #1: Which interventions will the patient/caregiver NOT be able to learn and perform?
Will the caregiver perform wound care? Help the patient perform the home exercise program? Flush the indwelling catheter?
A whole different careplan will be needed including more visits and resources when the caregiver is not fully available to meet the patient's needs. Except for #1, all of the following scenarios place enormous burden on the HHA to achieve outcomes, often with limited payer resources.
The Caregiver is Always the Admission Wildcard
1. Scenario #1: The caregiver is capable and fully available to meet patient needs. The ideal scenario.
2. Scenario #2: The caregiver is capable but unavailable to meet all patient needs. Additional services will be needed when the caregiver is not available.
3. Scenario #3: The caregiver is capable and available but requires training. More visits will be needed to train the caregiver.
4. Scenario #4: The caregiver is not capable. The caregiver has mental and/or physical limitations that will cause the patient's needs to go unmet. Unless the patient is fully alert and oriented the patient should not be admitted and postpone discharge from the current facility.
Important Question Number #2: Which Risk Factors are Unstable?
Medicare has long recognized that unstable risk factors will prompt an ER visit or hospitalization just as an unstable medical condition. The following are OASIS E1 risk factor questions, all of which require a careplan if unstable:
Deficits in the following can lead to...
• (B1300) Health literacy: the patient doesn't understand written instructions leading to compliance issues
• (A1250) Transportation: the patient is unable to make medical appointments leading to untreated issues
• (B1000) Vision deficit: causes falls and medication errors
• (B0200) Hearing deficit: a home safety issue, creates risk for injury
• (M1700) Cognitive Functioning: a home safety issue, patient is unable to recall preventive care including medication management
• (M1720) When Anxious: increased perceptions of needing medical care, may utilize health services more often leading to higher rate of hospitalization
• (D0160) Depression: increased perceptions of needing medical care, may utilize health services more often leading to higher rate of hospitalization
• (D0700) Social isolation: exacerbates serious physical health conditions
• (M2020) Oral Medication Management: inability to manage medications will lead to emergency room care
Additionally, Medicare requires us to assess the home for unsafe conditions and financial factors that will interfere with care.
Any unstable risk factor must always be included in the careplan.
IMPORTANT: Assign Risk Factor Management to the Office Case Manager
With field clinicians already overloaded with the patients medical and functional outcomes, assigning the case manager - in the office - to help with risk factors is highly recommended. The patient is socially isolated? the Case Manager can coordinate socialization activities. Home safety issues or transportation problems? The Case Manager can coordinate home repairs and transportation services.
OASIS-E1 O0110A: Are You Careplanning for Chemotherapy?
Teach the Patient/Caregiver How to Take a Blood Pressure
Rule #3 for Preventing Re-Hospitalization? Retire the Answering Machine
