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In my work as a home health nurse, I was usually shocked and saddened by the conditions of a person each time I visited a new patient in the homecare field.
I primarily worked with Medicaid and Medicare patients because they are the forgotten and most destitute of patients. There were many reasons for the depth of hopelessness and despair evident in the faces and home environment of my patients.
Lack of effectual and compassionate care in the home health situation remains one reason.
Many factors made this job a difficult one, but the patient was the one who suffered the most when home health did not perform as they should.
The task of assessing all previous diagnoses, intervening to find newer ones, and then beginning the process of teaching those diagnoses is a necessary component of the proper care of each patient.
Discovering that these crucial initial steps were usually not taken by either the admitting nurse or the previously assigned home health nurse of one of my patients was daunting and frustrating.
The heartbreak and difficulty in this nursing position was watching the majority of these patients (whose primary morbid diagnosis was longstanding, at least 10 years) neglect to follow through on their care plan and instructions, second to their loss of faith in their healthcare providers.
Unfortunately, one of the biggest barriers I experienced as the patient’s advocate (the number one job of a nurse) was disassembling the negative and discriminatory attitudes and perceptions that the patient’s medical providers had toward the patient.
Too many physicians and colleagues would give me reports of “combative and noncompliant” statuses for these patients, citing that they “just don’t take their medicine” or “they won’t keep their doctor’s appointments.”
Each report made me think differently of the messenger as my experience in many medical environments taught me early on that no one wants to be or stay sick. I understood that there is always an excess of conflicts and obstacles to the patient obtaining the necessities required to follow instructions or make it to their appointments.
Prescribers and providers often never address, investigate, or consider these important factors.
There are still only a handful of reputable providers who recognize this reality and attempt to bring some resolution to it by rightfully requiring their nursing staff to assist the patient in acquiring necessities, such as medical transportation covered by their insurance, or assistance in finding prescription programs to cover medicine copays.
Meeting just those needs goes a huge distance in increasing compliance of care instructions and appointment keeping. I have worked for just a few home health companies whose own creed to its patients was to liaise for them in this manner and those were the most fulfilling positions I had.
Miscommunication or lack of communication regarding the patient’s need for proper resources would result in the patient’s distrust of the home health company and the medical providers involved in meeting their needs. This perpetuated most “noncompliance.”
The home health nurse new to a patient should consider that a patient who has not had any previous home health or any positive previous home health experience may be slower to respond to recommendations and compliance-based instructions (medication regimen as an example.)
The home health field originated to end repetitive emergency room visits and “unnecessary” multiple office visits. It soon became a tool for the medical community to monitor better higher-risk patients’ daily compliance and decisions in diet, medication management, new onset of disease and progression, or reversal of co-morbidities (secondary diagnoses that complicate the primary diagnosis) among other issues.
It is a fantastic idea if implemented with honest intentions, intentions void of the notion to use this vulnerable population to glean as much revenue as possible from Medicaid and Medicare without providing the excellent care documented as performed.
In other words, be very aware of the pervasive cheats and frauds when searching for a home health company or in assessing the one a patient may already have.
They are everywhere and many times, hard to discern.
Extravagant agency offices seem to elicit false confidence in a “successful” company and smooth-talking Case Managers who promise the world usually deliver absolutely nothing.
If something feels wrong upon meeting with staff from a new company, or promises are not delivered, or visits are infrequent, and the patient is not getting better or fully supported, you need a new home healthcare provider.
Most of the home situations I walked into included the patients’ lamenting how a prior nurse had visited only once that month, yet they were supposed to have been seen once or twice a week. When investigated, it was documented (and meticulously, I might add) that there had been several visits that month that had already been billed to the insurance.
This dishonesty and unethical behavior left the patient without their medication refills, without the necessary medical oversight for their conditions and without advocacy between them and their providers, which, incidentally placed each one on the brink of an ER visit-the very situation that home health is there to prevent.
Much of the time I sent patients to the ER for very high blood pressure, infected wounds that had not been treated or dressed, or for the latent symptoms from a heart attack suffered at home. They had not gone to the ER and could not get a hold of their home health nurse to report the incidents.
These are real and frequent occurrences.
Professionally, I experienced the disregard for patient safety that some medical providers showed at times for their patients due to their refusal to provide proper basic care. These kind of providers often had signed contracts with local hospitals to divert patient emergencies away from the emergency room for “cost-effective” measures for those hospitals, in lieu of that physician taking steps to treat an emergency themselves. The intent on paper was to divert non-emergency situations from the ER, not true emergencies: however, this is not the situation I experienced in home health with some providers.
Heart attacks, strokes, extreme hypertension, and other serious conditions cannot be treated outside of the emergency room effectively. Patients lose their lives due to corporate contracts to “divert ER visits.”
Medicaid and Medicare patients were the only patients I knew of who were coaxed into signing these contracts with their physicians, as the providers had to have a patient’s signature to ensure their compliance in such situations.
Many patients relayed to me that they were informed they would have to find another doctor if they refused to sign these “call me first, do not go to the ER” contracts.
This flagrantly discriminatory tactic was and is incomprehensible and is not discussed openly with most nurses. My superiors had heard about it but did not have the details of the nuances of the contracts.
One physician, whom I called to report my patient having had two strokes between doctor’s visits, told me to send this patient (who was currently having stroke signs and symptoms) to his office, not the ER, because “My patients don’t go to the ER. They go through me, first.”
To clarify, this is medical negligence.
This particular patient had sat in the doctor’s office twice in the previous months while suffering active strokes and was now blind due to those incidents. Even after this physician saw the patient on those days, he declined for her to go to the ER for care and sent her home only with a higher dose of medication for her blood pressure.
This patient was not too interested in taking her medication as she didn’t trust her provider. After reporting the incidents and the situation to my supervisor, I assisted her in finding another medical provider. And, yes, I sent her to the ER.
To determine if the home care services you are currently receiving are deserving of your insurance dollars and time, ask these 7 questions:
Two weeks is a normal timeframe. Past that, call your MD and ask which company was faxed the order, call that company, or have the office nurse do this, and inquire about any holdups. Sometimes, insurance is the holdup. Other times, the chosen home health agency did not receive the order, lost the order, or was so disorganized that they themselves don’t know why they hadn’t called you.
2. When you do receive the initial call from a Case Manager to schedule your admission to home health, are they respectful of your time and schedule? If they communicate to you that they “only have this date and time available” to interview for admission (not all patients ordered home health will be admitted to any home health agency,) be wary. As nurses, we are being invited into your home to offer our services to you. You are not at our mercy. Your time and schedule should be considered for each agency appointment to visit you.
3. When a nurse comes to your home, do they respect your home environment? We need to know if you have animals or annoying/intrusive family members that would complicate a visit. Still, we certainly do not pass judgement regarding those or any other issues/situations in the home, barring criminal acts including drug use or abuse of the patient, which would have to be reported and reconciled through proper law and state enforcement.
4. Was your initial admission assessment thorough? This can last up to 2 hours. Use this guideline:
a) Full medical, social, and environmental (complete list of diagnoses and medical issues, family history and current status and issues, risks to your safety in the home) assessment taken?
b) Full assessment /inquiry as to any needs you may have?
c) Complete physical assessment including all body systems check, vital signs, blood sugar checked, equipment needs and checks, and oxygen saturation levels for oxygen-dependent patients. Needed equipment should be ordered immediately and delivered within a week at most.
d) Have all your questions answered to your satisfaction?
e) Explanation of the process of home health visits, documenting in the home (tablet or laptop usually) and how and when to reach either your nurse or the agency or the ER for health issues or questions you may have.
You should be provided with a working number answered by a nurse or knowledgeable agency staff at all times, day or night.
5. Have all of your medications been documented and all have recent refills and correct counts per the nurse? This is imperative to effectively managing your health and improving its status. This must be addressed and handled at EVERY home health visit.
6. After discussing your care plan (which includes the frequency of your visits, the diagnoses nursing will address and individual interventions, teaching and nursing tasks to be provided) do you understand it and agree to it?
7. Has an Emergency Plan been created and discussed with you? This includes exact instructions for the patient and family for handling weather emergencies, local, national disasters, and personal health crises.
In addition to the above, as a patient or family member of the home health patient, make sure that changes in health or problems with any delivery of care (such as not receiving ordered medical equipment) are reported to the home health nurse preferably at the time of occurrence but certainly at the very next visit.
As a combination strategy, medication refills are to be called in per the nurse and the patient/family member. However, ensure that refills are in the home before a home visit so that the nurse can properly dispense medication in a medbox if ordered.
When home visits are scheduled the patient must be educated on the fact that their nurse should arrive within an hour before or after the scheduled time due to several factors: length of time of the nurse’s previous home visit, possible emergencies or other patient needs, and the time to travel to the next patient.
Reporting the names of new doctors and any upcoming scheduled provider visit is imperative at each home health visit as there is usually a need during that home visit to include calls to the PCP or specialist.
In revisiting the original reason for home health, remember that the patient is to be properly and successfully cared for and should expect an outcome of improved health and stability, which helps reduce excessive in-clinic appointments, emergency room visits, and hospitalizations.
If these necessary benefits are absent from your home health care, determine your part in that, if any, and take action to change either your assigned nurse or the healthcare company immediately.
Yes, your life does depend on it.
References:
Expected standards of nursing care in the home:https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0264-9
This article shows how contracts should be handled in relation to reducing ER visits and NON-emergent health issues. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038086/
The requirements in this article are to be expected of nurses, as well. https://www.homecaremag.com/february-2019/chart-homecare-career
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